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FIRST  AID  DENTISTRY 
RYAN 


FIRST  AID  DENTISTRY 


BY 

E.  P.  R.  RYAN 

FIRST   LIEUTENANT,    DENTAL   SURGEON 
U.   S.   ARMY 


WITH  EIGHTY  ILLUSTRATIONS 


PHILADELPHIA 

P.    BLAKISTON'S   SON   &   CO. 

1012  WALNUT   STREET 


Copyright,  1914,  by  P.  Blakiston's  Son  &  Co. 


THE  MATX.E  PEESS  XOHK  Pi 


*) 


o 


THIS 

VOLUME 

IS 

FONDLY    DEDICATED 

TO 

MY  MOTHER 

WHOSE    ENCOURAGING    WORDS    AND    DEEDS 
HAVE    SERVED    ME    SO 

WELL 
THROUGHOUT  MY   LIFE 


PREFACE 

'Phis  book  has  been  designed  for  medical  and  dental 
practitioners  and  students,  for  nurses;  and  especially 
for  hospital  corps  men  of  the  military  and  naval  service 
and  for  all  who  are  called  upon  to  administer  relief  from 
dental  pain,  where  the  services  of  a  dental  surgeon  cannot 
be  obtained. 

The  impulse  prompting  this  book  was  not  to  multiply 
books,  but  arose  from  the  writer's  belief  and  that  ex- 
pressed by  many  practitioners,  both  medical  and  dental, 
that  this  hand-book  is  needed  by  those  it  is  intended  to 
serve. 

The  extent  and  scope  of  the  methods  described  are 
limited  to  First  Aid,  which  will  relieve  the  patient  from 
suffering  until  a  dental  surgeon  may  complete  the  treat- 
ment. A  minimum  number  of  instruments  is  recom- 
mended and  their  use  shown  and  described. 

The  methods  used  are  simple  and  the  descriptions  have 
been  written  in  the  simplest  words,  technical  terms 
being  eliminated  as  much  as  possible;  all  methods  used 
can  be  accomplished  on  board  ship  or  in  the  field  or  in 
any  hospital  or  medical  office. 

Due  credit  is  given  the  works  of  modern  writers,  which 
have  been  consulted  and  without  them  it  would  have  been 
impossible  to  accomplish  what  has  been  done. 

The  gratitude  of  the  writer  is  here  expressed  to  Captain 
J.  R.  Harris,  M.  C,  U.  S.  Army,  for  valuable  suggestions 
and  assistance;  and  special  credit  is  due  Mr.  H.  A.  Utter 
for  photos  from  which  these  illustrations  were  made. 

The  Author. 


CONTENTS 


Chapter  Page 

I.  Septic  Conditions  of  the  Mouth i 

II.  Salivary  Deposits 6 

III.  Inflammation  of  the  Mucous  Membrane  of  the  Mouth  .  16 

Stomatitis 16 

Herpes  Labialis 17 

Canker  "Sore  Mouth" .' 18 

Injuries  to  the  Membrane 19 

Smokers'  Sore  Mouth 20 

Marginal  Gingivitis 21 

IV.  Syphilis  in  the  Mouth 25 

Primary 26 

Secondary      27 

Tertiary. 29 

Differential  Diagnosis 30 

Ptyalism  (Salivation)      31 

V.  Brief  Dental  Anatomy 34 

Deciduous  Teeth      35 

Permanent  Teeth 36 

Structure  of  Teeth 37 

Enamel — Cementum — Dental     Pulp — Gums — Den- 
tine— Pericementum — Alveolar  Process 37 

VI.  Dental  Pain 42 

Inflammation  of  the  Pulp 42 

Putrescent  Pulp 44 

Pericementitis 46 

Non-septic 46 

Acute  Septic — Acute  Dento-alveolar  Abscesses      .    .  46 

Chronic  Dento-alveolar  Abscesses 49 

VII.  The  Treatment  of  Pulpitis S2 

VIII.  The  Treatment  of  Putrescent  Pulp  and  Non-septic 

Pericementitis 61 

IX.  The  Treatment  of  Abscesses 65 

Acute  Dento-alveolar 65 

Chronic  Dento-alveolar 67 

ix 


X  CONTENTS 

X.  Neuralgia 72 

Treatment:  Local  and  General 75 

XI.  Pyorrhea  Alveolaris 78 

Treatment  and  Instrumentation 84 

XII.  Fractures  and  Dislocations   of  the  Jaws  and  Their 

Treatment 88 

XIII.    Dental  Extractions 104 

Instrumentation 104 

Lancing      107 

Improvised  Dental  Chair 130 

XIV.  Post-operative  Conditions 134 

Pain  after  Extractions ' 134 

Hemorrhage  after  Extractions 135 

Fainting 137 

XV.  Diseases  of  the  Maxillary  Sinus — Antrum  of  Highmore 

Operations  and  Treatment 138 

Authors,  and  Books  Consulted 147 

Index. • 149 


FIRST  AID  DENTISTRY 


CHAPTER  I 
SEPTIC  CONDITIONS  OF  THE  MOUTH 

The  writer  does  not  intend  to  go  out  of  his  sphere  and 
make  suggestions  as  to  the  treatment  and  diagnosis  of 
disease  in  general,  but  merely  to  present  some  ideas 
from  a  denial  standpoint  which,  in  their  connection  with 
systemic  conditions,  are  frequently  overlooked. 

In  the  present-day  importance  of  opsonia  and  vaccine 
t  hcrapy  and  the  treatment  of  diseased  conditions  by  these 
methods,  greater  emphasis  should  be  placed  on  the  con- 
dition of  the  mouth,  with  regard  to  the  presence  of  patho- 
egenic  bactria.  The  oral  cavity  is  an  ideal  location  for 
the  cultivation  of  bacteria.  Nutrient  material  is  abun- 
dant, as  well  as  a  proper  temperature  and  in  most  mouths, 
predisposition. 

Consider  a  mouth  containing  many  necrosed  roots,  at 
times  floating  in  pus;  teeth  covered  by  tartar,  crowding 
the  tissue  and  preserving  undisturbed  shelves  under  the 
margins  of  the  gums,  for  retention  of  decomposing  food 
matter;  cavities  full  of  foul  germ-laden  substance;  ill- 
fitting  crowns,  plates  and  fillings.  It  is  hard  to  imagine 
more  favorable  conditions  than  these  for  the  growth  of 
disease-producing  germs. 

Miller1  found  upward  of  one  hundred  organisms  in  the 
mouth,  thirteen  varieties  being  common,  with  the  follow- 
ing pus-producing  organisms: 

1  "Micro-organisms  of  the  Human  Mouth,"  Miller. 


2  FIRST  AID   DENTISTRY 

Staphylococcus  pyogenes  aureus 34.8%  of  cases. 

Streptococcus  pyogenes ■ 23 . 2  %  of  cases. 

Staphylococcus  pyogenes  albus 18.6%  of  cases. 

Bacillus  pyocyaneus 9 . 3  %  of  cases. 

Staphylococcus  pyogenes  citrus 4.6%  of  cases. 

The  other  eight  varieties  being  harmless  and  varying  in 
frequency.  The  fact  that  the  staphylococcus  and  strep- 
tococcus organisms,  the  most  active  of  pathogenic  germs, 
are  present  to  this  enormous  extent,  should  impress  upon 
us  the  importance  of  the  mouth  as  an  etiological  factor  in 
disease. 

The  presence  of  these  organisms  is  not  to  be  considered 
merely  as  a  cause  of  inflammation,  stomatitis,  gingivitis 
and  local  effects,  which  are  seen;  but  it  must  be  further 
considered  that  the  mucous  membrane  of  the  rest  of  the 
alimentary  -tract  has  probably  less  power  of  resistance 
than  the  mouth.  The  wonderful  resisting  power  which  the 
mucosa  of  the  oral  cavity  exerts  and  its  ability  to  rebuild 
after  injury  is  known  to  all,  but  this  power  is  exerted  only 
to  resist  for  itself  and  to  throw  off,  not  to  destroy  or  render 
less  infectious,  the  cultures  we  swallow  continually. 

The  presence  of  pyorrhea  is  not  the  only  cause  of  many 
disease  conditions  which  we  trace,  or  should  trace,  to 
absorption  of  bacteria.  In  the  absence  of  pyorrhea,  other 
inflammatory  conditions  of  equal  importance  may  exist 
in  the  mouth. 

There  are  many  varieties  of  infectious  condition  of  the 
mucous  membrane,  which  will  be  dealt  with  in  the  follow- 
ing chapters.  Hunter1  has  stated  that  Tonsillitis  is  very 
frequently  the  result  of  mouth  infection;  and  the  probable 
cause  is  infected  sockets,  membranes  and  abscessed  teeth, 
the  drain  of  which  continually  passes  over  these  glands. 

A  mouth  which  abounds  in  tooth  decay,  stomatitis, 

l"Oral  Sepsis,"  Hunter. 


SEPTIC  CONDITIONS   OF   THE    8101  TH  3 

gingivitis  and  pyorrhea  alveolaris  is  a  perfecl  menstruum 
for  the  development  of  bacteria.  It  is  reasonable  to 
charge  to  'this  condition,  otherwise  diagnosed   disea 

especially  in  so  closely  related  organs  as  the  tonsils.  The 
importance  of  this  is  manifold,  since  many  other  diseases 
frequently  result  from  infection  of  the  tonsils  and  from 
pharyngitis;  and  other  affections  may  follow  where 
stomatitis  or  gingivitis  exist. 

Allan,  in  ''Vaccine  Therapy  and  Opsonic  Treat- 
ment," says  in  regard  to  the  administration  of  vaccines 
by  the  mouth,  that  favorable  results  were  obtained  in 
staphylococcal,  streptococcal,  pneumococcal  and  tuber- 
cular infections.  This  point  thus  arises.  If  vaccine  can 
be  successfully  administered  through  the  mouth,  what 
must  be  expected  where  pus,  laden  with  bacteria,  is  con- 
tinually swallowed? 

Latham  (quoted  by  Allen)  advocates  the  administration 
of  vaccines  by  the  mouth,  on  an  empty  stomach.  He 
considers  the  -absorption  to  be  almost  perfect  at  certain 
times.  We  must  expect  some  absorption  if  bacteria  and 
their  products  are  continually  swallowed  when  there  is 
little  or  no  hydrochloric  acid  in  the  stomach. 

Hunter1  attributes  to  mcfuth  organisms;  gastritis, 
septic  fevers,  profound  septicaemia,  anaemia,  tonsillitis, 
and  pharyngitis,  to  which  must  be  added,  via  the  tonsils, 
many  cases  of  muscular  and  articular  rheumatism. 
Aaron  Burr2  has  laid  out  a  plan  to  prevent  ocular  disease, 
by  the  remedy  of  this  oral  condition.  Miller3  points 
out  various  diseases,  such  as  diphtheria,  syphilis,  pul- 
monary diseases  and  disorders  of  the  digestive  tract, 
resulting  from  presence  of  bacteria  in  the  mouth. 

The  dentist  is  prone  to  discharge  the  patient  after  in- 

1  "Oral  Sepsis,"  Hunter. 

2  "Dental  Cosmos,"  July,  iqio. 

3  "Micro-organisms  of  the  Human  Mouth,"  Miller. 


4  FIRST  AID   DENTISTRY 

serting  beautiful  fillings,  crowns,  plates  and  appliances  for 
the  improvement  of  mastication;  and  to  overlook  the 
pus-ridden  sockets  and  necrosed  roots;  thus  leaving  a 
source  of  infection  discharging  as  before.  The  skillful 
surgeon,  who,  in  preparation  for  all  operations  on  the 
stomach  and  intestinal  tract,  is  punctilious  with  his  scrub- 
bing and  disinfection  beyond  the  slightest  point  of  criti- 
cism, would  consider  it  almost  criminal  to  close  an  opera- 
tion, knowing  he  had  a  drop  of  pus  in  the  wound,  yet 
many  to-day,  are  paying  no  heed  to  the  disinfection  of  the 
oral  cavity  prior  to  an  operation. 

Miller  and  others  have  shown  that  the  pathological 
organisms  can  be  killed  in  the  mouth  by  proper  steriliza- 
tion, yet  this  is  not  sufficient,  for  this  is  only  temporary 
asepsis  and  the  treatment  must  be  kept  up  a  sufficient 
length  of  time. 

In  diagnosing  gastric  disorders  the  absence  of  proper 
teeth  for  mastication  has  been  taken  into  consideration  as 
an  afterthought,  and  it  was  considered  -as  detrimental 
in  the  disease.  Tooth  destruction  was  considered  a  result 
of  regurgitated  ferments  from  the  stomach.  This,  how- 
ever, is  the  crudest  conception,  these  conditions  should  be 
considered  as  the  cause  and  not  the  result  of  the  gastric 
disorders. 

• 

Treatment  and  Sterilizating 

As  described  in  Chapter  II,  calcareous  deposits  should 
be  removed,  teeth  cleaned  and  polished,  all  spaces  be- 
ing cleaned  by  floss,  rubbers,  etc.,  roots  extracted  and 
the  sockets  which  are  flowing  with  pus  should  be  sponged 
out  with  a  solution  of  listerine,  5  per  cent,  phenol  or 
DobelPs  solution  in  hot  water.  The  writer  has  had  suc- 
cess in  using  tincture  of  iodine,  placed  on  a  pledget  of 


SEPTIC   CONDITIONS   OF   THE   MOUTH       •  5 

cotton  and  forced  to  the  bottom  of  these  sockets,  the 
cotton  being  removed  at  once  and  followed  with  proper 
syringing.  Necrosed  alveoli  should  be  scraped  and  par- 
ticles removed. 

For  painful  sockets  a  pledget  of  cotton  saturated  with 
campho-phenique  or  tincture  of  calendula  is  used  to 
good  advantage;  or  a  thin  paste  of  orthoform  and  iodo- 
form, equal  parts,  made  with  campho-phenique  may  be 
used;  the  pledget  being  left  in  the  socket  for  twelve  hours. 
When  the  mouth  has  been  treated  in  this  way,  if  the  edges 
of  the  gums  around  the  teeth  are  very  much  inflamed,  it 
is  well  to  paint  these  raw  surfaces  with  a  5  or  10  per  cent, 
solution  of  resorcin,  a  saturated  solution  of  tannic  acid  in 
tincture  of  iodine,  or  a  good  counter-irritant.  Then  in 
twenty-four  hours  it  will  be  well  to  have  the  patient  use  the 
brush  with  a  little  powdered  pumice  once  or  twice,  as  di- 
rected in  the  following  chapter,  and  continue  the  mouth 
wash,  allowing  plenty  of  time  for  the  antiseptic  action  of 
the  solution. 


CHAPTER  II 

SALIVARY  DEPOSITS 

When  the  patient  comes  for  emergency  treatment,  it 
is  because  he  has  suffered.  In  many  cases,  this  is  the  only 
reason  why  he  seeks  relief  or  treatment.  Our  first  duty 
is  to  give  him  relief.  The  various  conditions  with  their 
emergency  treatment  will  be  taken  up  by  subjects  in  the 
succeeding  chapters.  The  following  chart  shows  the  per- 
centage of  men  who  were  treated  by  the  writer  during  a 
recent  period,  the  ages  ranging  from  18  to  35  years,  where 
salivary  calculus  was  present  in  each  case  and  who  were 
asked  the  question:  " Do  you  clean  your  teeth? "  Having 
treated  these  men,  the  veracity  of  the  small  percentage 
who  claim  they  clean  their  teeth,  is  doubted. 


Patients  treated                 a               b 

c 

d 

Total 

540                          99             72 

21 

348 

54° 

Explanation. — Teeth  cleaned     . 

a.  Three  times  daily. 

b.  Once  a  day. 

c.   Once  a  month. 

d.  Never  cleaned. 

This  percentage  of  patients  who  come  for  emergency 
treatment  is  met  with  in  every  day  practice. 

When  a  patient  presents  himself  with  fetid  breath, 
swollen,  bleeding  gums  and  large  masses  of  deposits  on  the 
teeth,  with  no  individual  tooth  aching,  there  is  evident 
lack  of  care  and  the  condition  demands  emergency  treat- 
ment. There  are  two  distinct  kinds  of  deposits,  or  tartar 
(as  it  is  sometimes  called)  on  the  teeth.     The  two  most 

6 


SAIIYXk'V    DEPOSITS  7 

frequent  locations  for  it  are  jusl  behind  and  on  the  lower 
margins  of  the  lower  incisors,  joining  and  impinging  on  the 
gums,  and  on  the  buccal  or  cheek  side  of  t  be  upper  molars. 
This  is  caused  by  the  proximity  of  the  ducts  of  salivary 
glands,  the  sub-maxillary  and  sub-lingual  for  the  lower 
incisors  and  the  parotid  glands  for  the  molars. 

The- deposition  of  tartar  is  not  a  normal  condition,  as  it 
is  seldom  found  in  wild  animals,  or  people  like  the  Indians, 


Fig.  i.  Salivary  calculus  on  the  right  side  of  the  mouth  where  teeth 
were  all  in  place  and  occlusion  would  be  normal,  were  calculus  removed. 
Presented  for  pain  on  this  side  of  the  mouth.     Result  of  neglect. 


who  use  their  teeth  with  gross  food,  so  it  naturally  follows 
that  the  kinds  of  food  we  use,  lack  of  exercise  of  the  organs, 
and  lack  of  care,  account  largely  for  its  presence. 

As  stated  above,  there  are  two  kinds  of  tartar,  viz., 
serumal  and  salivary.  Serumal,  as  the  name  implies, 
is  deposited  from  the  serum  of  the  blood  and  is  always 
originally  located   under  the  free  margins  of   the  gums, 


8  FIRST  AID  DENTISTRY 

where  the  blood  supply,  coming  into  contact  with  the 
tooth,  deposits  it.  This  is  the  form  found  in  patches  or 
small  rings  on  the  sides  and  necks  of  the  teeth.  Some 
writers  believe  it  to  be  the  most  dangerous  class,  because 
it  is  very  hard  and  irritating  to  the  peridental  membrane 
and  is  believed  to  play  a  large  part  in  the  etiology  of 
pyorrhea  alveolaris. 


Fig.  2. — Opposite  side  of  same  mouth,  one  tooth  missing,  absence  of 
calculus  because  of  use  for  mastication. 

Salivary  calculus  is,  as  the  name  implies,  derived  from 
saliva,  the  analysis  of  which  is  as  follows  (quoted  from 
Tome's  "Dental  Surgery"): 

Salivary  Calculus 

Earthy  phosphate 79  •  o 

Salivary  mucus / .  .  .  12.5 

Ptyalin 1 .  o 

Animal  matter  in  hydrochloric  acid 7-5 


SALIVARY   DEPOSITS  9 

Salivary  deposits  are  found  in  great  quantities  in  neg- 
lected mouths.  The  writer  has  removed  masses  which 
have  completely  covered  a  tooth,  no  opposite  tooth  occlud- 
ing. Not  only  is  the  deposit  of  tartar  to  be  taken  into 
consideration,  but  where  there  are  large  patches,  under 
the  margin  and  in  the  shelf  formed  by  them  and  the  gum 
will  be  found  a  veritable  hot-bed  of  bacteria,  and  in  all 
probability  some  formation  of  pus.  If  there  is  an  inflam- 
mation and  irritation  of  the  alveolar  process,  this  emer- 
gency demands  your  attention.  The  bacteriological 
aspect  resulting  from  this  condition,  and  the  mouth  in  gen- 
eral, has  been  taken  up  in  another  chapter. 

It  is  the  intention  of  the  writer  to  make  plain  the  treat- 
ment, the  methods  and  the  instrumentation  for  remov- 
ing deposits,  which  will  relieve  the  immediate  condition 
presented. 

The  proper  removal  of  deposits  is  not  a  simple  matter 
and  to  successfully  clean  away  this  irritating  substance 
will  test  the  skill  of  a  good  operator.  The  description  of 
a  simple  method  of  relieving  this  condition,  will,  how- 
ever, be  attempted. 

There  are  two  principal  plans  of  procedure  for  removal 
of  deposits,  the  push  cut  and  the  draw  cut  methods.1 
Only  the  draw  cut  method  will  be  suggested  in  this  chapter. 
The  daily  use  of  the  push  cut  method  renders  the  process 
easy,  but  the  occasional  use  of  this  method  is  not  advised. 
The  draw  cut  method  does  not  alarm  the  patient  because 
he  feels  you  are  drawing  the  instrument  away  from  the 
sensitive  tissues.  The  scalers  in  Fig.  3  are  photo- 
graphed from  two  views,  showing  the  shape,  form  and 
cutting  edges.  These  four  instruments  will,  if  diligently 
applied,  render  relief  in  all  cases  presented  for  emergency 
treatment.     Grip  the  instrument  with  the  thumb  and  first 

1  ''Principles  and  Practice  of  Filling  Teeth,"  Johnson. 


IO 


FIRST   AID   DENTISTRY 


finger  while  the  second  finger  forms  a  guard  or  fulcrum; 
then  holding  the  instrument  beneath  the  calculus,  draw 
it  on  the  long  axis  of  the  tooth  away  from  the  gums. 


Fig.  3. — Four  scalers  which  can  be  used  with  success  in   removal   of 
deposits  on  the  teeth  (side  and  front  view). 

Figs.   4   to   8   demonstrate   the  position  and  protection 
of  the  lips,  etc.,  with  the  left  hand  during  this  process. 

There  is  no  fear  of  cavities  under  these  deposits  of  salts, 
because  their  presence  must  have  resulted  from  the  exist- 


SALIVARY    DEPOSITS 


II 


ence  of  an  alkaline  reaction  and  we  have  no  caries  except 
in  acid  reaction? 

Patients  firmly  believe  at  times,  that  cavities  must  exist 
on  the  lower  anterior  teeth  where  deposits  have  pushed 
the  gums  away  and  exposed  the  peridental  membrane. 
This  at  times  is  very  sensitive  and  too  much  force  on  the 
instrument,  with  too  much  pressure  against  the  tooth, 


FlG.  4. — Method  and  position  of  the  instrument  and  fingers  for  remov- 
ing deposits  from  the  upper  incisors.  The  position  of  the  second  linger 
of  right  hand  will  be  noted  as  forming  a  fulcrum. 


should  be  avoided.  There  is  no  possibility  of  removing 
the  enamel  with  the  deposit,  because  it  is  merely  a  foreign 
matter  attached  to  the  enamel;  and  while  it  clings  in  many 
cases,  it  will  be  removed  by  perseverance  and  proper  in- 
strumentation. The  engine  with  bristle  brushes  and 
wooden  points,  rubber  cups,  etc.,  is  ordinarily  used  alter  all 
the  deposits  have  been  removed,  but  this  being  only  an 
emergency,  the  medicinal  treatment  should  now  be  applied. 


12 


FIRST  AID   DENTISTRY 


Paint  the  edges  of  the  gums,  when  they  are  inflamed  with 
resorcin,  10  per  cent,  solution,  tincture  oT  iodine,  or  the 
counter-irritant  tincture  of  iodine,  tincture  of  aconite  and 
chloroform  equal  parts;  then  give  the  patient  a  good  anti- 
septic mouth  wash.  Instruct  him  how  to  use  it  in  hot 
water,  holding  a  quantity  of  same  in  the  mouth,  for  a  few 
minutes  each  time  used,  and  on  the  following  day  to  mas- 


Fig.  5. — Method  of  removing  deposit  from  upper  right-side  of  mouth, 
showing  protection  of  lips  with  left  hand. 


sage  the  gums  with  the  fingers.  Then  on  the  second  day, 
have  him  use  a  small  quantity  of  powdered  pumice  stone 
as  a  tooth-powder  and  give  the  instructions  on  care  of  the 
teeth.  Cleaning,  not  medicine  and  fancy  mouth  washes, 
aids  nature  most  in  reverting  to  (the,  normal  conditions. 
Instruct  the  patient  in  properly  brushing  the  teeth,  to 
place  the  bristles  of  the  brush  on  the  gums  and  by  a  down- 
ward or  rotary  movement  of  the  hand,  bring  the  bristles 


SALIVARY  DEPOSITS 


13 


Fig.  6. — Showing  position  oi  instrument  and  first  finger  of  left-hand  which 
prevents  instrument  from  slipping  and  injuring  the  gums. 


Fig.  7. — Position  for  removal  of  deposits  from  inner  surface  of  lower 
central  with  use  of  the  mirror. 


14 


FIRST   AID   DENTISTRY 


over  the  teeth.  For  the  lower,  the  bristles  will  be  placed 
on  the  gums  and  an  upward  or  circular  movement  will 
give  the  same  result,  completing  a  circle  with  the  brush. 
Then  brush  over  the  cutting  edges  and  inside  by  the 
straight  in  and  out  motion.  For  the  inside  of  the  lowers 
use  a  lift  movement  of  the  bristles  and  brush  the  cutting 
surfaces,  the  same  as  the  upper.     Use  floss  silk  for  remov- 


FiG.  8.' — Position  of  the  instrument  in  removal  of  deposits  from  labial 
or  outer  surfaces  of  lower  centrals,  showing  protection  of  the  lips  and  ful- 
crum formed  by  second  finger. 


ing  particles  of  food  between  the  teeth,  where  the  contact 
points  are  bad  and  strands  of  food  are  held.  Do  not 
snap  the  floss  silk  down  and  injure  the  gums,  in  the  inter- 
proximal spaces.  The  use  of  the  wooden  toothpick  is 
injurious  and  absolutely  unwise,  as  it  works  great  havoc 
with  the  gums  and  the  peridental  membrane  of  the  teeth. 
In  case  any  pick  is  used,  the  quill  is  permissible,  being  soft 


SALIVARY  DEPOSITS  1 5 

and  pliable  and  there  is  no  chance  of  splinters  being  left 
to  injure  the  gums. 

Many  powders,  liquids  and  paste  tooth  preparations 
on  the  market  are  more  detrimental  than  nothing  at  all. 
A  good  paste  makes  the  habit  of  cleaning  the  teeth  more 
attractive  and  pleasant.  The  main  point,  however,  in  all, 
is  the  proper  use  of  the  tooth  brush  with  plenty  of  water. 


CHAPTER  III 

INFLAMMATION  OF  THE  MUCOUS  MEMBRANE 
OF  THE  MOUTH 

Stomatitis. — A  catarrhal  inflammation  of  the  mucous 
membrane  of  the  mouth,  which  is  divided  etiologically 
into  many  classes.  Marshall  makes  a  classification  as 
follows:  "stomatitis  simplex,  stomatitis  catarrhal,  sto- 
matitis apthosa,  stomatitis  parasitica  and  stomatitis 
ulcerosa."  This  classification  meets  the  demands  of 
differential  diagnosis  very  well  indeed;  however,  only  the 
local  conditions,  as  a  whole,  will  be  dealt  with  in  this 
chapter. 

The  various  causes  of  stomatitis  are  both  local  and  con- 
stitutional. Among  the  local  irritants  are  bad-fitting 
plates,  bridges,  crowns  and  fillings,  and  rough  edges  caus- 
ing irritation;  also  unhygienic  conditions  in  bottle-fed 
children.  Constitutional  causes  include  malnutrition, 
conditions  caused  by  unhealthy  quarters,  various  dis- 
eases which  alter  the  condition  of  the  blood,  as  scarlet 
fever,  diphtheria,  scrofula;  effects  of  medicines,  such  as 
the  use  of  mercury,  etc.  There  can  be  no  doubt  that  para- 
sitical conditions  of  the  mouth  enter  into  this  etiology. 

The  surgeon  in  charge  of  the  case  should  be  consulted, 
as  to  the  systemic  condition.  Its  treatment^from  this 
standpoint,  should  always  be  directed  by  him,  especially 
as  to  changes  of  treatment  causing  this  condition. 

Ill-fitting  plates,  bridges,  crowns  or  fillings  should  be 
removed  and  not  replaced  in.  the  mouth  until  the  condi- 
tions are  healed  or  repaired. 

16 


MUCOUS  MEMBRANE  OF  THE  MOUTH        17 

The  local  treatment  of  nearly  all  cases  should  be  as 
follows:  The  mouth  should  be  irrigated  with  boric  acid 
solution,  DobelFs  solution  or  other  mild  antiseptic,  with 
a  wash  at  some  stage,  always,  of  potassium  chlorate,  gr.  v, 
to  the  ounce  of  water.  Surfaces  with  glistening  patches 
coalescing  until  the  whole  mucous  membrane  seems 
covered  should  be  treated  with  emmolient  lotions,  such 
as  borax  and  honey,  glycerine,  weak  solution  of  acetate 
of  lead,  gr.  iii,  to  the  ounce  of  water,  or  a  very  weak  solu- 
tion of  alum.  A  few  doses  of  potassium  bromide  will 
relieve  the  nervous  condition.1 

A  great  many  men  who  live  in  barracks  and  eat  the  same 
prepared  food  will,  at  times,  seem  to  present  an  epidemic, 
which  is  simple  stomatitis.  The  irritated  parts  should  be 
touched  with  resorcin,  10  per  cent,  or  tincture  of  iodine. 
If  the  patient  be  given  a  good  cathartic  and  advised  to  re- 
frain from  the  eating  of  meats,  and  given  a  glass  of  good 
strong  lemonade,  twice  daily,  for  about  three  days,  the 
normal  condition  will  generally  return. 

Herpes  Labialis  (Fever  Blisters). — An  acute  inflamma- 
tory affection,  characterized  by  the  formation  of  vesicles, 
or  groups  of  same,  on  the  skin  or  mucous  membrane. 

Herpes  is  called  fever  blisters,  also  "cold  sores,"  these 
names  arise  from  the  etiology,  being  frequent  in  all  kinds 
of  fevers  and  when  the  patient  is  suffering  from  a  cold  or 
intestinal  indigestion. 

Forming  blisters  on  thejips,  they  are  very  liable  to  be 
broken,  and  when  they  are  they  become  very  painful. 
The  adjustment  of  the  rubber  dam  and  all  other  dental 
work  over  the  lips,  which  might  injure  or  bruise  the  tissues, 
cause  their  appearance  and  they  may  persist  and  recur, 
because  some  patients  are  of  a  herpetic  diathesis. 

l"  Dental  Medicine,"  Gorgas. 


FIRST   AID   DENTISTRY 


Treatment 


Clean  the  affected  part  with  alcohol  or  hydrogen 
peroxide  and  apply  oil  of  cloves,  or  campho-phenique 
(the  latter  being  much  preferred) . 

A  large  sore  which  is  liable  to  break  and  bleed  may  be 
kept  soft  by  the  use  of  zinc  oxide  ointment.  Very  painful 
sores  result  from  the  vesicles  breaking  and  from  exposure 
to  the  wind,  etc.,  and  these  raw  surfaces  should  be  washed 
clean  with  hydrogen  peroxide  or  alcohol  and  then  seared 
with  campho-phenique  and  a  thin  layer  of  cotton  placed 
over  the  part  and  this  covered  with  Collodium. 

Canker  "Sore  Mouth. " — Canker  sores  are  very  small, 
angry  ulcers  with  a  coating  of  whitish  yellow  over  the 
surface.  The  size  varies  from  that  of  a  grain  of  wheat  to 
a  pea.  They  are  generally  located  on  the  tongue,  at  its 
junction  with  the  ground  or  floor  of  the  mouth,  as  well  as 
on  the  buccal  surfaces  at  the  duplicature  of  gums  and 
buccal  membrane.  They  vary  in  depth  according  to  the 
stage  of  progress  and  are  always  painful,  they  are  generally 
round  and  the  margins  well  defined,  but  these  must  not 
be  confused  with  the  more  perfectly  defined  margins  of 
the  chancrous  ulcer.  The  membrane  around  the  ulcer 
is  always  red  and  inflamed.  Pressure  within  an  inch  will 
cause  pain  at  the  point  of  contact.  The  writer  has  ob- 
served them  to  appear  suddenly  in  men,  especially  after 
excessive  or  unaccustomed  use  of  alcoholic  beverages,  and 
they  are  common  in  pregnant  women,  appearing  and 
reappearing. 

Authors  differ  as  to  the  cause  of  canker  sore  mouth, 
many  believe  their  origin  to  be  solely  in  the  mouth  while 
others  attribute  their  cause  to  trophic  disturbances.1 
The  duration,  characteristic  appearance,  size,  pain,  and 

1Pusey:  quoted  by  Buckley. 


MUCOUS     MIMI.K'WI      <>!•'    Till.     M()l    Ml  IQ 

location  of  these  ulcers  renders  diagnosis  comparatively 

easy. 

Treatment 

The  mouth  should  be  washed  out  with  a  good  antiseptic 
mouth  wash  (the  writer  prefers  it  made  with  hot  water, 
always),  such  as  listerine,  Dobell's  solution,  or  5  per  cent, 
carbolic  acid  solution  with  a  few  drops  of  the  oil  of  gual- 
theria  or  cassia,  dissolved  in  alcohol,  added;  this  held  in 
the  mouth  for  a  minute  or  two.  The  ulcer  should  then 
be  washed  with  a  pledget  of  cotton  saturated  with  perox- 
ide and  the  whitish-gray  surfaces  cleared  off;  the  part 
should  then  be  dried  wtih  alcohol  and  touched  with  a 
10  per  cent,  solution  of  nitrate  of  silver,  which  cauterizes 
deeply  enough,  but  does  not  penetrate  too  far,  because  of 
the  forming  of  a  firm  coagulation.1  A  pledget  of  cotton 
saturated  with  pure  carbolic  acid  will  also  be  found  very 
useful.  The  writer,  after  using  one  of  these  applications 
generally  paints  the  inflamed  area  immediately  around 
the  ulcer  with  tincture  of  iodine,  or  iodine,  aconite  and 
chloroform,  equal  parts.  The  patient  will  be  relieved 
immediately  by  this  method  and  seldom  requires  a  second 
treatment.  The  mouth  wash  should  be  continued  for 
from  twenty-four  to  forty-eight  hours. 

Injuries  of  the  Mucous  Membrane 

Very  severe  injuries  to  the  mucous  membrane;  inflamed, 
swollen  patches  and  surfaces  present;  which  are  the  re- 
sult of  injuries  to  the  tissues.  The  bristles  of  the  tooth 
brush  may  penetrate  under  the  margins  of  the  gums,  or 
any  other  part  with  which  the  brush  comes  into  contact 
in  cleaning,  and  result  in  this  condition  to  the  extent,  of 

1  Prinz. 


20  FIRST  AID   DENTISTRY 

forming  an  abscess.  This  may  be  mistaken  for  an  abscess 
of  the  tooth,  or  a  "pyorrhea  alveolaris  socket."  The 
writer  recently  treated  a  patient,  a  young  lady,  who  had 
been  under  treatment  for  six  months  for  supposed  dento- 
alveolar  abscess  of  the  upper  right  central  incisor.  It  was 
considered  incurable  and  she  was  advised  to  have  the 
tooth  removed.  Careful  exploration  showed  the  pus  com- 
ing from  the  side  of  the  root,  and  presence  of  some  for- 
eign substance  under  the  gums  about  the  middle  of  the 
root,  which  could  not  be  removed.  Incision  was  made 
opposite  this  point  and  a  pus  pocket  opened.  The  con- 
tents were  examined  and  a  coarse  bristle  from  the  tooth- 
brush found.  The  abscess  was  treated,  drained  and 
closed,  and  the  root  filled,  with  resultant  complete  dis- 
appearance of  condition. 

A  hair,  a  bristle,  a  piece  of  a  wooden  toothpick,  or  a 
seed  or  any  foreign  substance  of  this  class,  may  be  found 
to  be  the  cause  of  this  painful  condition. 

Treatment 

Removal  of  the  foreign  substance  and  the  part  washed 
with  a  warm  mouth  wash  and  touched  with  tincture  of 
iodine,  or  aconite,  iodine  and  chloroform,  equal  parts,  on 
a  pledget  of  cotton,  will  effect  a  cure. 

Smokers'  Sore  Mouth. — Many  excessive  smokers  will 
present  large,  swollen,  very  red,  dry  patches  on  the  roof 
of  the  mouth,  extending  over  the  palate,  which  are  ex- 
tremely painful,  in  reality  blisters. 

Treatment 

Wash  the  mouth  with  a  warm  solution  of  carbonate  or 
bicarbonate  of  soda,  or  magnesia  water,  dry  the  surfaces 


MUCOUS  MEMBRANE  OF  THE  MOUTH         21 

affected  with  a  pledget  of  cotton  saturated  in  alcohol, 
then  paint  the  surface  with  glycerite  of  tannin.  Let  the 
patient  hold  a  5-grain  tablet  of  chlorate  of  potassium  in 
his  mouth  until  it  dissolves,  not  chewing  it,  then  in  two 
hours,  another  one,  and  after  that  he  will  be  able  to  smoke. 
If  not  repeat  the  treatment. 

Gingivitis. — Gingivitis  is  an  inflammation  of  the  gums 
and  when  the  margins  are  so  affected,  as  shown  in  Fig.  9, 
it  is  designated  as  "marginal  gingivitis." 

In  nearly  all  cases  where  marginal  gingivitis  exists,  we 
have  a  subsequent  degeneration  of  the  pericementum,  the 
membrane  of  attachment  of  the  roots  of  the  teeth  to  the 
socket.  This  condition  is  almost  certain,  unless  proper 
treatment  is  instituted,  to  result  in  a  gingivitis  of  the 
deeper  tissues  and  interstitial  gingivitis,1  as  Talbot  has 
wisely  called  the  condition  commonly  known  as  pyorrhea 
alveolaris. 

Marginal  gingivitis  may  be  caused  by  local  irritation, 
local  infection  and  general  effects  of  various  origin,  un- 
hygienic quarters,  food,  general  debility,  disease,  drugs, 
such  as  mercury,  etc.;  gonococcus  bacteria  are  claimed  to 
have  been  found  in  some  forms  of  gingivitis. 

In  the  case  shown  in. Fig.  9,  the  patient  had  recently 
recovered  from  typhoid  fever  and  showed  absolute  neglect 
of  his  teeth  and  mouth.  Plaques  of  deposit,  crowned  the 
necks  of  all  the  teeth,  these  were  covered  by  soft  masses 
of  decayed  food,  lying  unmolested  in  a  fermenting  con- 
dition, far  from  the  disturbances  of  mastication.  The 
resistance  to  the  treatment  of  this  condition  was  proof  of 
systemic  involvement  and  bacteriological  infection,  aided 
by  local  irritation  of  deposits  and  food  wedged  between 
the  teeth. 

Marginal  gingivitis  appears  at  the  necks  of  the  teeth, 

1  "Interstitial  Gingivitis,"  Talbot. 


22 


FIRST   AID   DENTISTRY 


presenting  a  red,  swollen,  inflamed  surface,  which  bleeds 
with  the  slightest  touch,  the  gums  are  easily  raised  away 
from  the  deposit  and  are  raw  and  very  painful.' 

Salivary  deposits  are  generally  present  or  some  other 
mechanical  object  of  irritation,  such  as  ill-fitting  crowns, 
fillings,  plates,  bridges,  etc.,  or  the  existence  of  bad  con- 
tact points,  which  permit  the  food  to  lie  unmolested  be- 
tween the  teeth  and  result  in  a  fermentation,  irritating 
the  gums  to  inflammation.     Too  violent  brushing  of  the 


Fig.  9 — Marginal  gingivitis;  the  result,  of  neglect  of  teeth.  Patient 
recently  dismissed  from  hospital,  case  of  typhoid  fever.  Mouth  had  not 
been  treated  or  cared  for,  by  his  statement  and  by  appearance. 

teeth  and  the  use  of  too  strong  astringent  mouth  washes, 
will  also  cause  the  inflammation. 

When  gingivitis  appears  in  more  than  one  or  two  places, 
that  is,  a  general  gingivitis  on  the  margins  of  all  of  the 
teeth,  it  is  usually  the  result  of  local  irritation,  salivary 
deposits. 

These  irritated  points  form  shelves  between  the  margins 
of  the  gums  and  the  tartar  and  present  an  ideal  location 
for  the  fermentation  of  food,  as  well  as  an  injured  raw 


MUCOUS   MEMBRANE   OF   THE   MOUTH  2$ 

surface,  open  to  the  attack  of  the  oral  bacteria.  The 
<^ums,  pushed  away  from  the  necks  of  the  teeth,  arc  very 
spongy,  very  much  swollen  and  congested,  with  irregular 
attachments  to  the  teeth;  and  at  times  present  a  purple 
appearance,  indicating  excessive  congestion. 

This  condition  treated  and  proper  care  of  the  mouth 
given  by  the  patient  will  prevent  subsequent  development 
of  the  more  serious  and  positive  interstitial  gingivitis  or 
pyorrhea  alveolaris. 

Treatment 

Local  treatment  will  ease  the  condition  and  prevent 
further  developments,  unless  an  underlying  constitutional 
condition  is  the  cause.  The  following  treatment  will  aid 
and  be  necessary  even  in  the  presence  of  the  correction  of 
this  condition.  Wash  the  mouth  with  a  warm  solution  of 
half  and  half  Dobell's  solution  and  wTater;  5  per  cent, 
phenol,  or  a  weak  solution  of  potassium  permanganate  or 
a  solution  of  the  mouth  wash  given  below,  then  with  the 
same  method  as  employed  in  the  removal  of  deposits,  as 
shown  in  Figs.  4  to  8,  remove  the  calculus  and  food  debris 
from  around  the  necks  of  the  teeth  and  again  flush^out 
the  sockets  which  appear  at  the  margins.  The  gumswill 
be  very  tender  and  tear,  almost  at  the  touch  of  the  in- 
strument; but  care  will  prevent  this  to  any  great  extent 
and  the  profuse  bleeding  will  help  reduce  the  congestion. 
Take  an  orange  wood  stick,  preferably,  trim  it  to  a  flat 
surface  and  paint  the  rough  raw  surfaces  with  a  10  per  cent, 
solution  of  trichloracetic  acid,  this  will  tend  to  reduce  and 
astringe  these  affected  surfaces.  With  a  pledget  of  cot- 
ton, saturated  with  tincture  of  iodine,  paint  over  all  the 
affected  parts. 

Give  the  patient  a  good  mouth  wash,  such  as: 
3 


24  FIRST  AID  DENTISTRY 

1$.    Boroglycerinae,1 

Tinct.  of  kramerias, 

Tinct.  of  calendulas, 

Alcoholis aa  30  c.c. 

Sig. — Two  tablespoon fuls  to  a  glass  of  water  several  times 
daily. 

The  writer  has  found  this  wash  to  have  a  very  curative 
effect  upon  the  injured  tissues.  Let  the  patient  use  this 
for  one  day  after  treatment,  then  proper  care  and  brush- 
ing of  the  teeth,  will,  in  most  cases,  prevent  a  recurrence. 

1  Burchard  and  Inglis. 


CHAPTER  IV 
SYPHILIS  IN  THE  MOUTH 

Syphilis  will  be  dealt  with,  not  from  the  standpoint 
of  the  general  practitioner,  treating  the  case,  constitution- 
ally, but  from  that  of  the  dental  operator.  Too  much 
emphasis  cannot  be  placed  upon  its  importance  to  those 
who  operate  with  the  object  of  dental  relief. 

Some  men  in  the  past  have  felt  that  they  should  not 
treat  dental  cases,  where  syphilitic  symptoms  were  present 
or  suspected.  In  our  province  of  relieving  pain,  we  can- 
not admit  to  a  patient  that  we  are  not  sufficiently  cautious, 
skillful  and  informed  to  successfully  treat  him  without  in- 
fecting ourselves  or  our  other  patients. 

First-aid  treatment  in  these  cases,  is  as  necessary  and  at 
times,  more  gratifying,  than  in  many  others.  The  writer's 
experience  has  been  that  syphilitics  are  exceedingly  pleased 
to  have  rubber  gloves  used  and  all  other  precautions  taken 
in  treating  their  cases.  One  of  the  most  agonizing  cases 
of  dental  suffering  the  writer  has  ever  treated,  was  a 
syphilitic,  presenting  abscessed  teeth  and  necrosed  roots, 
immediately  under  a  large  oozing  mucous  patch.  The 
practice  advocated  by  some  men,  of  the  destruction  of  in- 
struments after  using  in  suspected  syphilis,  is  expensive, 
useless,  and  foolish;  since  a  good  scrubbing  with  green 
soap  and  boiling  in  a  sterilizer  for  not  less^than  fifteen 
minutes,  will  suffice  to  make  sure  of  asepsis. 

When  we  know  that  the  patient  has  syphilis  and  he 
comes  for  dental  treatment,  precautions  must  be  taken,  yet 
the  value  of  extra  precaution  must  be  considered  in  all 

25 


26  FIRST  AID   DENTISTRY 

patients,  because  we  do  not  ordinarily  know  that  patients 
are  syphilitic.  Syphilis  is  not  a  respecter  of  persons,  sex, 
age,  position  or  society  and  patients  the  least  suspected 
may  carry  the  spirochseta  of  the  scourge. 

Primary  Syphilis 

The  primary  lesion  of  acquired  syphilis  appears  from 
ten  to  ninety  days,  an  average  of  twenty-one  days  after, 
and  at  the  point  of,  infection.  Appearing  as  an  eroded, 
hard  papule,  losing  its  coating  after  a  few  days,  it  is  raw, 
ulcerated  and  surrounded  by  a  tough,  hard  ring.  The 
lesion  is  called  the  chancre  and  is  painless.  The  lymphatic 
glands  lying  in  adjacent  parts  become  swollen. 

The  important  point  in  this  work  is  the  extra-genital 
chancre,  which  appears  so  frequently  on  the  lips,  in  the 
mouth,  on  the  fingers,  etc.,  and  may  be  the  direct  result 
of  ignorance  or  neglect  in  the  care  of  instruments,  appli- 
ances and  the  hands  of  the  operator.  Keyes  gives  a  table 
of  seventy  cases  of  extra-genital  chancres,  which  will 
serve  to  emphasize  the  importance  of  this  fact  by  the 
various  locations  given: 

Cases  Cases 

Males 70  Tonsils 2 

Finger 34  Cheek 1 

Lip 24  Chin 1 

Tongue 4  Eyelid 1 

Abdomen 2  Arm 1 

Keyes  states  that  almost  all  the  finger  infections  are  of 
doctors,  due  to  contact  with  affected  parts.  Care  of  the 
hands  as  well  as  protection  of  patients  is  again  emphasized. 
The  treatment  is  constitutional  and  within  the  province 
of  the  general  practitioner. 


SYPHILIS    IX    THE    MOl   I  II 


27 


Secondary  Syphilis 

The  secondary  manifestations  of  syphilis  will  generally 
be  observed  in  and  about  the  mouth,  irrespective  of  the 
location  of  the  initial  chancre.  These  are  not  local  in- 
fections, but  the  result  of  the  general  progress  of  the  dis- 
ease. The  eruptions  of  this  stage  are  found  alike  on  the 
skin  and  the  mucous  membrane.  Certain  organs  may 
show  the  result  of  acute  inflammation.  At  the  time  of  the 
fevers  accompanying  the  eruptions,  mucous  patches  occur 
on  the  mucosa  of  the  mouth  and  in  any  part  of  the  oral 


Fig.   10 — Typical  case  of   herpes  labialis.     (Cold  sores  or  fever  blisters. > 

cavity.  The  pharynx  and  the  larynx  are  also  affected 
by  the  inflammation.  The  copper-colored  areas  (like 
pus  seen  through  a  membrane  over  the  point  of  a  boil) 
appear  under  the  outer  mucous  lining,  on  some  part  of  the 
membrane  of  the  lips,  palate,  buccal  or  labial  regions. 
pharynx  or  tonsils.  They  soon  break  down  and  form  the 
mucous  patches  which  are  the  most  virulent  and  danger- 
ously infectious  lesions  of  the  disease. 

This  condition  is  of  paramount  importance  to  the  oper- 
ator on  the  oral  cavity,  as  the  lesion  can,  at  times,  scarcely 
be  diagnosed  from  the  ordinary  "fever  blisters'"  > herpes 


28  FIRST   AID   DENTISTRY 

labialis).  Illustrations  No.  10  and  No.  n  show  two  cases 
which  the  writer  treated  for  dental  pain  on  the  same  day. 
Compare  the  vicious,  painful  patch  of  Herpes  with  the 
more  innocent  appearing,  painless  mucous  patch.  Diag- 
nosis of  this  condition  at  any  time  must  be  determined  by 
other  signs  of  syphilis,  in  other  parts  of  the  body,  as  en- 
larged glands,  skin  eruptions,  areas  of  papular  eruption 
on  the  membrane  of  the  throat;  also  other  signs,  as  falling 
out  of  hair,  eyebrows,  etc.     Frequently  a  diagnostic  sign 


Fig.  ii — Syphilitic  chancre.  The  one  on  the  reader's  right  was  full 
of  pus  just  under  the  outer  mucous  membrane — the  black  spot  indicates 
the  yellow  pus  in  the  tissue. 

is  that  of  indefinitely  located  dental  pain.1  The  point 
of  importance  for  the  dental  operator  is  to  be  able  to 
determine  these  conditions  and  to  take  precautions  for 
his  patient's  and  his  own  protection;  to  refer  the  case  to  a 
general  practitioner  for  systemic  treatment  if  the  patient 
is  not  under  his  care  at  the  time. 

The  use  of  mercury  in  these  cases,  is  almost  universal; 
even  with  the  present  use  of  salvarsan,  mercury  is  and 
should  be  used  as  a  following  treatment.     The  appearance 

^ugenschmidt:  quoted  by  Burchard. 


SYPHILIS   IN   THE   MOUTH  20 

of  ptyalism  has  been  much  reduced  by  the  new  combina- 
tion. However,  a  prophylactic  treatment  of  the  oral 
cavity  limits  the  possibility  of  ptyalism,  and  mercury  can 
be  pushed  much  further  without  salivation  if  the  mouth 
has  been  placed  in  a  proper  condition. 

Tertiary  Syphilis 

The  lesions  of  secondary  syphilis  are  confined  principally 
to  the  mucous  and  dermal  tissues  but  the  lesions  of  the 
tertiary  stage  arise  in  the  deeper  connective  tissues  and 
the  periosteum,  most  often  attacking  the  bones  with  thin 
portions,  such  as  the  bones  of  the  skull,  palate,  palatal 
process1  and  the  alveolar  process. 

Tertiary  lesions  will  be  noted  by  the  oral  operator  in 
the  form  of  ulcers,  which  appear  first  on  the  soft,  then  on 
the  hard  palate,  on  the  lips,  and  on  the  tongue.  They 
make  their  appearance  usually  as  nodes  under  the  skin  or 
mucous  membrane,  and  become  larger  as  they  approach 
the  surface  and  break  gradually  through,  forming  an  ulcer. 
This  may  perforate  the  palate  and  the  extensive  necrosis 
will  at  times  totally  destroy  the  bones  of  the  surrounding 
parts.  The  more  frequent  affection  in  the  mouth,  how- 
ever, is  the  bone  of  the  upper  jaw.  When  the  lower  bone 
is  affected,  according  to  Marshall,  it  is  generally  in  the 
alveolar  process.  He  states  a  case  where  the  palatal  bones, 
the  nasal  bones  and  nearly  the  entire  upper  jaw,  were 
destroyed,  the  soft  palate  being  intact. 

These  ulcers  are  malignant  in  the  extreme  and  attack, 
impartially,  every  organ.  Under  treatment,  systemic  or 
local,  they  have  very  little  tendency  to  disappearance. 
Authorities  differ  as  regards  the  possibilities  of  infection 
from  these  lesions.     Keyes  states  that  "  they  are  clinically 

1  Keyes. 


30  FIRST  AID  DENTISTRY  g 

not  infectious."  However,  an  ugly,  stubborn  ulcer  in 
the  mouth  of  a  patient  should  be  looked  upon  with  great 
caution  and  the  same  care  be  taken  in  operating  and  ster- 
ilizing, etc.,  as  with  other  stages.  Trauma,  such  as  injury 
of  dental  tissues  in  treating  the  pulps  of  teeth,  abscesses, 
pyorrhea  alveolaris,  extractions,  etc.,  may  be  the  cause  of 
extensive  necrosis  in  cases  with  a  history  of  syphilis.  It 
does  not  matter  what  has  been  the  result  of  its  treatment 
and  the  confidence  of  its  cure. 

In  case  of  accidental  infection  from  an  instrument  used 
on  a  syphilitic  patient,  an  ointment  composed  of  ten  parts 
of  calomel  and  twenty  parts  lanolin,  applied  by  inunction 
to  the  infected  part,  will  probably  prevent  syphilitic 
infection  if  used  within  one  hour  of  the  inoculation. 
Mercuric  chloride  is  claimed  to  be  of  no  avail.1 


Differential  Diagnosis  of  Chancre  and  Herpes 
(Taken  from  Keyes) 

Syphilitic  Chancre  Herpes 

i.  History: 
Sexual  contact,  kissing,  mediate     Relapsing  herpes, 
infection,  vaccination,  etc. 

2.  Incubation: 

Two  to  six  weeks.  None. 

3.  Commencement. 

Begins  as  an  erosion  or  papula  Begins  as    a  group  of    vesicles, 

and   remains  an  erosion  or  ul-  rarely  as  a  single  vesicle,     and 

cerates.  becomes  an  ulcer. 

4.  Number: 

Usually  unique  or  simultane-  Usually  multiple  simultane- 
ously s  multiple,  rarely  multiple  ously  and  by  successive  crops 
by  successive  auto-inoculation,  of  vesicles  sometimes  confluent, 
never  confluent. 

1  Metchinoff :  quoted  by  Burchard  and  Inglis. 


SYPHILIS   IN   THE    MOUTH 


31 


Syphilitic  Chancre 
5.  Physiognomy: 
(a)  Shape:  round,  oval  or  sym- 
metrically irregular. 


(b)  Lesion:  is  habitually  flat, 
capped  by  erosion  or  superficial 
ulceration;  or  scooped  out,  or  a 
deep  funnel-shaped  ulcer  with 
sloping  edges.  Sometimes  the 
papula  is  dry  and  scaly. 

(c)  Edges:  sloping  and  adher- 
ent. Sometimes  prominently 
elevated. 

(d)  Bottom:  smooth,  shining. 

(e)  Color:  somber,  darkish  red, 
gray  or  black,  sometimes  livid 
and  scaly,  occasionally  scabbed. 

(f)  Secretion:  slight,  serosan- 
guinolent,  unless  irritation  pro- 
vokes suppuration. 

8.  Induration:  Constant, 
parchment  like  and  very  faint, 
or  cartilaginous  and  extensive, 
terminating  abruptly  not  shad- 
ing off  into  parts  around; 
movable  upon  parts  beneath  the 
skin  and  not  adherent  to  the 
latter,  outlasts  the  sore  and  re- 
main for  months  usually. 

9.  Sensitiveness:  Absent. 

10.  Duration:  At  least  a  fort- 
night. 


Herpes 

(a)  Shape:  irregular,  rounded 
with  borders  describing  seg- 
ments of  small  circles  left  by 
confluent  vesicles. 

(b)  Lesion:  usually  superficial, 
sometimes  in  solitary  Herpes 
there  is  but  one  absolutely  cir- 
cular vesicle.  There  are  usually 
neighboring  vesicles  to  clear  up 
the  diagnosis. 

(c)  Edges:  sharp,  not  under- 
mined. 

(d)  Bottom:  even,  inflamma- 
tory. 

(e)  Color:  like  chancre. 


(f)  Secretion:  slight, 
lent. 


seropuru- 


Induration:  inflammatory,  capa- 
ble of  being  produced  by  some 
cause  as  in  the  chancroid  and 
behaving  in  a  precisely  similar 
manner. 


Beginning,  heat. 

Rarely  more  than  ten  days. 


Ptyalism  (Salivation) 

In  the  treatment  of  syphilis,  the  administration  of  mer- 
eury  is  necessary  in  more  than  the  tonic  dose.     In  many 


32  FIRST  AID  DENTISTRY 

cases  the  patient  must  be  poisoned  to  cure  the  lesion. 
Mercury  is  an  alterative  and  tonic  in  small  doses  but  in 
severe  cases  of  syphilis  it  is  pushed  far  beyond  this  point. 
Mercurialism  as  shown  by  the  gums,  or  mild  salivation, 
indicates  the  stopping  of  its  administration.  The  stop- 
ping of  the  mercury  will,  in  these  mild  cases,  affect  a  cure. 
Mercury  has  a  selective  influence  on  the  gums,  jaws  and 
adjacent  parts.1  In  more  severe  cases,  the  first  symp- 
toms noticed  by  the  patient  are  a  coppery,  metallic  taste 
in  the  mouth,  fetor  of  the  breath,  inflammation  of  the 
gums  and  swollen  tongue,  showing  the  imprint  of  the 
teeth.  The  gums  bleed  freely  and  a  severe  pericementitis 
of  the  teeth  is  present,  with  much  pain  when  the  jaws  are 
forcibly  closed.  If  the  drug  is  not  withdrawn,  the  condi- 
tion grows  worse,  saliva  flows  from  the  mouth,  there  is 
drooling  and  the  tongue  swells,  teeth  become  so  loose  in 
the  sockets  that  they  may  be  picked  out  with  the  fingers 
(they  should  not  be  extracted,  however).  The  glands 
swell  and  ulcerations  occur  in  the  mouth.  Mercurial 
ulceration  appears  behind  the  lower  incisors  and  back  of 
the  lower  wisdom  teeth;  finally  the  soft  tissue  sloughs  and 
necrosis  of  the  bone  sets  in  and  sequestra  form,  whose 
subsequent  removal  is  necessary. 

Treatment 

The  care  of  the  mouth  for  the  prevention  of  salivation 
has  been  described  above.  Any  patient  who  is  to  be  given 
a  course  of  treatment  with  mercury  should  have  all  irri- 
tating crowns,  bridges,  or  plates  repaired  or  removed,  all 
roots  extracted  and  be  instructed  to  be  conscientious  in 
the  brushing  of  his  teeth  and  gums  properly,  at  least  three 
times  daily;  and  be  given  a  mouth  wash,  such  as  potassium 

1  Buckley. 


SYPHILIS   IN   THE    MOUTH  33 

chlorate,  gr.  xv,  dissolved  in  half  a  tumbler  of  water,  for 
hardening  the  gums. 

The  patient  with  a  profuse  flow  of  saliva  should  be 
given  refrigerating,  acidulated  drinks.  The  ulcerations 
may  be  touched  with  tincture  of  aconite,  tincture  of 
iodine,  and  chloroform  or  with: 

Tinct.  of  Myrrh.  1 

Tinct.  Iodum  Comp.     >  aa  4  gms. 

Aquas  J 

Sig:  Apply  to  gums  once  or  twice  daily.1 

Atropin  in  medicinal  doses  may  be  used  by  the  physician 
in  charge  to  control  the  excessive,  flow  of  saliva.  The 
systemic  treatment  should  not  be  changed  except  by  him. 

When  the  evidence  of  necrosis  is  at  hand  and  the  parts 
can  be  treated,  Mawhinney  recommends  the  local  appli- 
cation of  50  per  cent,  solution  of  phenosulphic  acid,  which 
acts  as  a  stimulant  and  hastens  the  formation  of  sequestra. 

1  Buckley. 


CHAPTER  V 

BRIEF  DENTAL  ANATOMY 

In  order  to  intelligently  treat  or  relieve  dental  disturb- 
ances, it  is  necessary  for  the  operator  to  have  a  knowledge 


Lower  cent. 

incisor 

4-7  months 


Lower  lat. 

incisor 

12-15  months 


Lower 

cuspid 

18-24  months 


Lower  first 

pre-molar 

12-15  months 


Lower  second 

pre-molar 

20-30  months 


Upper  cent. 

incisor 

8-10  months 


Upper  lat. 
incisor 
8-10  months 


Upper 
cuspid 
18-24  months 


Upper  first 
pre-molar 
12-15  months 


Upper  second 
pre-molar 
20-30  months 


Fig.  12. — The  deciduous  teeth  and  time  of  their  appearance  (left  side 
of   mouth  only). — {From  BroomelL) 

of  the  parts,  their  construction,  relation,  organs  of  supply, 
histology  and  functions.     It  is  not  intended  to  give  in  this 

34 


BRIEF   DENTAL  ANATmn 


35 


chapter  a  full  and  extensive  treatise  on  this  large  and  Im- 
portant 1  (ranch,  but  to  give  a  few  ideas  which  will  aid  in 
all  emergency  treatments  presented. 


UPPER  TEETH 

Labial  view 

Third  molar 
17-21  years 

Second  molar 
12-14  years 

First  molar 

5-6  years 

Second  bicuspid 

10-12  years 

First  bicuspid 

9-10  years 

Canine 

1 1- 1 2  years 

Lat.  incisor 

7-9  years 

Cent,  incisor 

6-8  years 


LOWER  TEETH 

Lingual  view 
Central  incisor 
6-8  years 
Lateral  incisor 
7-9  years 
Canine 
1 1 -1 2  years 
First  bicuspid 
9-10  years 
Second  bicuspid 
10-12  years 
First  molar 
5-6  years 

Second  molar 
12-14  years 

Third  molar 
17-21  years 


Fig.  13. — Eruption  of  the  permanent  teeth. — (From  Broomcll.) 


The  temporary  or  deciduous  teeth  number  five  on  each 
side,  from  the  median  line  backward,  the  full  set  being 
ten  in  each  jaw.  These  teeth  erupt  from  the  fifth  to  the 
thirtieth  month  and  complete  their  full  service  with  the 


36 


FIRST  AID  DENTISTRY 


eruption  of  the  permanent  set.  The  chart,  Fig.  12,  shows 
the  time  of  eruption  of  the  temporary  teeth,  and  chart, 
Fig.  13,  the  eruption  of  the  permanent  teeth.  Comparison 
of  these  figures  and  tables  will  show  that  the  time  of  the 
loss  of  the  temporary  teeth  is  about  that  of  the  eruption 
of  the  corresponding  permanent  teeth. 

The  importance  of  this  comparison  of  the  relative  time 
of  loss  and  eruption  should  be  seriously  considered  in  the 
decision  as  to  the  advisability  of  extracting  deciduous 
teeth.     Premature  or  delayed  extraction  may  result  in  a 


Fig.  14. — The  teeth  in  position  with  extreme   alveolar  plate  removed, 
showing  relative  position  of  the  roots. — {Johnson.) 


malocclusion  and  compel  the  patient,  in  a  few  years,  to 
undergo  the  tedious  process  of  regulation  of  the  perma- 
nent set.  Deciduous  teeth  should  not  be  extracted  when 
they  ache  any  more  than  permanent  teeth,  but  the  treat- 
ment of  the  condition  should  be  made  to  preserve  the  teeth 
for  their  full  period  of  usefulness. 

Fig.  14,  by  Johnson,  is  an  excellent  exhibit  of  the  two 
sets  of  teeth  in  situ.  The  external  plates  of  the  alveolar 
process  being  removed,  the  reader  is  able  to  secure  an  ac- 
curate idea  of  the  angles,  position  and  relation  of  the  roots 
of  the  various  classes  of  teeth,  as  they  normally  exist. 


BRIEF  DENTAL  ANATOMY 


37 


Fig.  15  presents  the  diagram  of  the  structure  and  im- 
plantation of  the  normal  incisor  tooth,  a  study  of  which 
will  fix  in  the  mind  the  exact  anatomy  and  relation  of 
the  teeth.  Those  having  multiple  roots  have  the  same 
histology  and  source  of  supply  for  each  root. 

Enamel 


Dentine 

Dentinal  tubulae 

Pulp 

Vein 


Dental 
periosteum 


Artery 
Nerve 


W    'i.V 
Cementum <®rv® 

Opening  at  apex    — 


Pericementum 


'pi —     Bone  of  jaw 


Fig.  15. — Vertical  section  of  an  incisor  tooth. 

The  Enamel 

The  enamel  is  the  hardest  and  most  compact  part  of 
the  tooth,  the  part  which  forms  the  outer  exposed  surface 
and  covers  the  crown.  It  is  formed  in  prisms  or  rods, 
lying  generally  parallel  to  each  other  and  resting  at  one 
extremity  on  the  dentine.  The  rods  are  held  together 
by  a  very  minute  layer  of  cement  substance,  presenting  a 
solid  mass  to  the  naked  eye. 


The  Dentine 

The  dentine  is  the  tissue  which  forms  the  principal  mass 
of  the  tooth.     It  is  a  modification  of  bony  tissue,  differing, 


38  FIRST   AID   DENTISTRY 

however,  in  that  the  cells  lie  only  at  the  periphery  of  the 
pulp,  and  not  throughout  the  mass.  The  dentine  is 
formed  around  the  chamber  which  encases  the  pulp.  The 
mass  is  traversed  by  small  canals  (dentinal  canaliculi) 
which  run  in  a  course  from  the  pulp  outward,  as  is  shown 
very  clearly  in  the  figure.  These  canals  contain  a  sub- 
stance, called  the  intertubular  tissue  and  communicate 
sensation  from  the  point  of  stimulation  to  the  pulp.  The 
dentine  is  surrounded  or  covered  by  the  enamel  in  the 
crown  portion  of  the.  tooth,  and  the  cementum  in  the 
root  portion. 

The  Cementum 

The  cementum  is  the  covering  over  the  root  portion  of 
the  tooth.  It  varies  in  thicknesses,  overlapping  the  edges 
of  the  enamel  at  the  neck,  and  becoming  thicker  over 
the  apical  portion.  The  cementum  is  truly  a  bone  sub- 
stance, and  contains  Haversian  canals  in  its  thicker 
portion,  about  the  apex.  As  age  advances,  the  cementum 
becomes  thicker,  especially  on  the  outer  border. 

The  Pericementum 

This  membrane,  for  such  it  is,  affords  a  lining  for  the 
alveolar  sockets  of  the  roots  of  the  teeth.  It  also  forms  the 
attachment  between  the  cementum  on  the  inner  surface 
and  alveolar  process  on  the  outer  surface,  both  of  which 
it  nourishes,  being  profusely  supplied  with  nerves  and 
blood-vessels.  The  fibers  from  the  membrane  form  the 
firm  attachment  of  the  teeth  in  the  socket;  by  entering 
into  the  substance  of  the  bone  on  the  one  side,  and  the 
cementum  on  the  other.  The  pericementum  is  larger,  or 
thicker  at  the  apical  end  of  the  roots.     In  the  powerful 


BRIEF  DENTAL  ANATOMY  39 

concussion  of  the  teeth  in  mastication  this  membrane 
acts  as  a  shock  absorber,  so  to  speak.  Being  quite  clastic, 
it  permits  the  teeth  to  move  about  in  their  sockets.  More- 
over the  pericementum  has  a  sensory  function.  It  is  the 
medium  by  which  all  forces  applied  to  the  tooth  surface 
are  taken  up  and  conveyed  to  the  brain.1 

The  important  point  in  this  brief  description  is  the  part 
played  by  this  membrane  in  dental  pain,  by  reason  of 
its  richly  supplied  nerves  and  blood-vessels  and  its 
functions. 

The  Dental  Pulp 

The  dental  pulp,  erroneously  called  the  nerve,  occupies 
the  chamber  or  pulp  canal,  in  the  center  of  the  tooth. 
It  is  not  a  nerve  tissue,  but  iibrous  cellular  connective 
tissue,  and  is  abundantly  supplied  with  blood-vessels  and 
nerve  libers.  These  gain  their  entrance  through  the 
opening  at  the  apical  end  of  the  root,  or  roots.  As  the 
tooth  may  have  a  different  number  of  roots,  so  it  must 
have  a  corresponding  number  of  apical  openings  for  the 
supply  of  the  vessels  and  nerves. 

The  pulp  serves  as  the  menstruum  for  holding  the  odon- 
toblasts, or  dentine-forming  cells,  which  lie  at  the  periph- 
ery, the  pulp  being  forced  back  as  the  process  of  dentine 
building  continues,  until,  in  old  age,  the  pulp  chambers 
are  nearly  closed  and  the  pulp  receded. 

The  vessels  of  the  pulp  are  very  numerous,  entering  the 
apical  foramen  in  three  or  more  branches1  they  form  a 
plexus  which  is  the  cause  of  the  profuse  bleeding  from 
the  pulps,  in  their  removal. 

The  nerves  generally  enter  by  one  large  trunk  and  three 
or  four  minute  branches.     After  pursuing  a  parallel  course, 

1  Broomell. 


40  FIRST  AID  DENTISTRY 

giving  off  branches  in  the  body  of  the  pulp,  they  form  a 
rich  plexus  beneath  the  edges  of  the  developing  dentine.1 
The  relationship  and  the  structure  of  the  dental  pulp  must 
be  understood,  for  intelligent  treatment  of  the  greatest 
of  maladies  in  emergency  treatment. 

The  Alveolar  Process 

The  alveolar  process   of   the  maxillary   bones,   is   a 
strong  and  wide  ridge  of  bone,  which  forms  the  root 
sockets.     The   alveolar  process   consists   of   two   plates, 
an  inner  and  an  outer;  and  these  are  connected  by  septa, 
which  separate  the  sockets  of  the  teeth.     A  process  of  a 
jaw  without  the  teeth,  looks  like  a  solid  bone,  with  the 
sockets  drilled  out  for  the  respective  roots  of  the  teeth. 
The  bone  in  the  septa  has  a  soft,  spongy  structure,  very 
easily  broken  and  many  times  septa  are  carried  out  be- 
tween the  roots  of  the  teeth,  in  extraction.     The  upper 
edges  are  thin  and  vary  in  width  at  different  teeth;  viz, 
over  the  cuspid  teeth,  the  bone  is  thinner  than  in  any  other 
part  and  fractures  are  frequently  located  here  by  reason 
of  this  fact.     The  process  at  the  outer  surface  of  tiie  lower 
third  molar  teeth  is  very  short  and  thick  and.at.the  inner 
surface,  very  thin  (a  point  to  be  remembered  ^extrac- 
tions).    The  reverse  is  practically>ue  of  the  upper  third 
molars.     This  process  being  spongy  and  sharp  at  the 
edges,  is  easily  broken  down,  after  the  tooth  it  supports 
is  removed. 

The  Gums 

The  gums  are  continuances  of  the  mucous  membrane 
of  the  mouth,  differing  from  other  membranes  by  their 

1  Tomes. 


BRIEF   DENTAL   ANATOMY  4 1 

greater  density,  being  composed  of  fibrous  tissue.  The 
gums  are  hard  and  elastic  and  closely  connected  with  the 
periosteum  of  the  alveolar  process,  seemingly  a  con- 
tinuous tissue.  The  gum  tissue  is  scantily  supplied  with 
nerves  and  sensibility  is  limited.  Its  ability  to  reconstruct 
or  rebuild  itself  after  injury  is  marked. 


CHAPTER  VI 
DENTAL  PAIN 

The  pain  presented  being  proved  not  to  be  a  result  of 
calculus,  stomatitis,  gingivitis,  etc.,  of  the  foregoing  chap- 
ters, or  of  pyorrhea  alveolaris  or  neuralgia,  it  will  be  pain 
from  the  individual  teeth.  Toothache,  in  the  words  of 
the  poet,  Burns,  "The  Hell  of  all  Diseases,"  to  be  suc- 
cessfully treated  must  be  properly  located  and  then  diag- 
nosed as  to  the  cause  when  it  is  a  simple  matter  to  effect 
the  cure. 

There  are  several  kinds  of  toothache,  which  are  the 
results  of  various  causes,  which  will  be  studied  in  order  to 
accomplish  what  we  are  called  upon  to  do. 

Pulpitis 
(Inflammation  of  the  Dental  Pulp) 

A  tooth  may  ache  from  an  exposure  of  the  pulp,  where 
the  structures  have  been  dissolved  out  and  undermined 
and  the  germs  of  decay  have  opened  a  path  for  various 
irritations  to  the  pulp-tissue,  a  point  of  irritation  and 
inflammation. 

The  pulp  may  also  be  exposed  and  inflamed  under  a 
leaky  filling,  or  one  which  has  been  placed  in  the  tooth 
without  proper  removal  of  decay  or  sterilization  of  the 
cavity. 

Pulp  exposures  may  result  from  the  injudicious  use  of 
strong  acids,  which  have  been  pumped  into  pockets  under 
the  gums,  in  the  treatment  of  pyorrhea  alveolaris.     The 

42 


DENTAL  PAIN  43 

tooth  structure  will  be  destroyed  and  obscure  cavities 
form  which  will  be  very  hard  to  find.  Errors  in  diagnosis 
are  very  liable  to  occur  in  these  cases. 

Another  is  by  mechanical  abrasion,  the  teeth  become 
worn  and  in  older  persons,  the  enamel  entirely  ground 
away,  the  dentine  grooved  and  the  pulp  exposed.  In  the 
writer's  practice,  a  man  sixty  years  of  age,  with  apparently 
sound  teeth,  from  the  labial  view,  could  not  close  his  mouth 
because  "He  felt  it  was  close  to  the  quick."  The  lingual 
or  inner  part  of  the  upper  right  central  was  so  worn  and 
grooved  by  the  lower  that  the  nerve  was  entirely  exposed. 

The  pulps  may  become  exposed,  also  from  fractures  of 
the  teeth,  either  by  forcibly  bringing  the  jaws  together  in 
a  way  to  split  them  or  by  a  blow.  Many  times  a  pulp 
will  become  inflamed  and  die  without  the  patient  knowing 
it,  from  the  result  of  a  slight  injury  to  a  tooth. 

There  is  another  pain  which  we  find  in  a  live  tooth,  the 
formation  of  pulp-stones,  or  rather  secondary  dentine,  calco- 
spherites.  The  dentine  cells  not  being  forced  to  the 
periphery,  mass  in  the  body  of  the  pulp.  This  is  a  very 
confusing  and  tedious  condition  to  diagnose  and  treat. 
Fortunately  emergency  treatment  except  that  used  in 
pulpitis,  will  not  be  necessary. 

Diagnosis 

{Exposure  of  the  Dental  Pulp) 

When  this  condition  exists,  the  pain  is  such  that  the 
patient  will,  in  most  cases,' have  no  doubt  as  to  the  tooth 
affected.  Nevertheless,  exploration  should  be  made  with 
a  mirror  and  a  sharp  fine  explorer.  When  the  cavity  is 
found,  press  the  tooth  gently,  but  firmly,  with  the  finger 
and  tap  it  with  an  instrument.  This  will  not  cause  in- 
creased pain,  because   the  peridental   membrane  is  not 


44 


FIRST  AID  DENTISTRY 


affected.  Heat,  carried  by  means  of  a  small  piece  of  gutta- 
percha, heated  in  an  alcohol  flame,  held  in  a  pair  of  dress- 
ing pliers,  applied  on  the  enamel,  will  intensify  the  throb- 
bing; as  will  also  lowering  the  head,  since  either  increases 
the  congestion  of  blood^irTthe "already  hyperaemic  pulp. 
A  very  slight  amount  of  cold  may  be  applied  by  a  small 
stream  of  cold  water  from  a  syringe,  where  there  is  doubt, 
and  this  will  more  than  intensify  the  pain.  The  history 
of  the  tooth,  as  to  injuries,  mechanical  irritants  and  treat- 
ments of  pyorrhea  alveolaris,  will  be  taken  into  consider- 
ation in  determining  this  condition  if  the  above  methods 
fail. 

Putrescent  Pulp 

The  difference  between  life  and  death,  in  any  tissue, 
organ  or  body,  is  very  comprehensible  and  makes  a  great 
classification.  In  regard  to  the  dental  pulp,  it  is  the  most 
important  point  in  determining  the  trouble  and  treat- 
ment. Patients  will  present  with  swollen  jaws,  from 
dento-alveolar  abscess  and  remark  that  the  "nerve  is  ex- 
posed." Such  a  fallacy  will  readily  be  seen,  as  the  tooth 
cannot  be  abscessed,  except  by  the  death  of  the  pulp. 
Death  of  the  pulp  is  preceded  by  the  process  of  inflam- 
mation. Irritation  causes  hyperemia,  which  is  one  of 
the  first  causes  of  pain,  in  pulpitis.  Following  this,  patho- 
genic bacteria  enter  and  the  decomposition  of  the  pulp 
sets  in,  literally,  the  death. 

This  condition  of  the  pulp  is  the  beginning  of  various 
kinds  of  diseases.  Septic  pericementitis,  dento-alveolar 
abscess,  etc.  By  the  decomposition  of  the  complex  sub- 
stances of  the  dental  pulp,  two  gases  are  formed,  ammonia 
and  hydrogen  sulphid.  Poisonous  ptomaines  and  fats  are 
also  found,  the  result  of  putrefaction;  this  condition  is  the 
putrescent  pulp. 


DENTAL  PAIN  45 

Putrescent  pulps  form  as  a  result  of  caries,  fractures, 
thermal  changes,  teeth  carrying  large  fillings  and  other 
conditions,  which  cause  the  irritation  and  inflammation 
of  the  pulp  associated  with  infection.  The  gases  held  in 
the  pulp-chamber,  unable  to  escape  through  the  tooth, 
result  in  the  formation  of  a  septic  pericementitis,  or  a 
dento-alveolar  abscess,  by  forcing  septic  matter  through 
the  apical  opening. 

Putrescence  (the  presence  of  gases)  is  the  result  of  in- 
flammatory process,  with  putrefaction,  fermentation,  and 
infection  from  bacteria,  in  the  pulp-chamber. 

Diagnosis 

The  anterior  teeth  are  more  easily  diagnosed,  when 
putrescent  pulps  exist,  because  there  is  less  possibility  of 
a  partial  life  and  death  of  the  tissues,  than  in  the  multi- 
rooted teeth;  and  reflection  of  light  through  the  tooth  is 
more  readily  accomplished.  These  teeth  present  a  bluish 
or  brownish  discoloration  through  the  larger  part  of  the 
pulp-chamber  and  hot  instruments  or  gutta-percha  have 
no  effect  nor  has  the  application  of  cold  to  the  surfaces  of 
these  teeth.  If  the  cavity  is  open,  the  patient  will  notice 
a  bad  odor  and  taste  from  the  leakage  of  gases  and  septic 
matter.  A's  a  rule,  there  is  no  soreness  at  the  end  of  the 
roots,  but  pressure  will  make  the  patient  feel,  at  times, 
the  abnormal  condition  of  the  tooth,  which  is  generally 
not  loose.  The  gases  which  escape  from  these  teeth,  upon 
the  opening  of  the  chamber  will  be  sufficient  to  prove  the 
diagnosis.  The  odors  of  hydrogen  sulphid  and  ammonia 
and  of  the  putrefaction,  will  need  only  be  smelled  once,  to 
be  always  recognized  as  those  of  a  putrescent  pulp- 
chamber. 


46  first  aid  dentistry 

Pericementitis 

Pericementitis  is  the  inflammation  of  the  peridental 
membrane  of  the  tooth  and  is  divided  into  two  classes: 
non-septic  and  septic.  The  non-septic  is  caused  by  me- 
chanical or  drug  irritants1  such  as  root  fillings,  ill-fitting 
dentures,  plates,  crowns,  bridges,  the  hammering  in  the 
insertion  of  large  gold  fillings,  or  crowns  left  too  long, 
causing  a  pounding  on  the  tooth  in  occlusion;  and  drugs 
used  in  the  treatment  of  these  teeth. 

Diagnosis — Non-septic  Pericementitis 

In  pericementitis,  not  caused  by  the  presence  of  septic 
matter  or  bacteria,  we  have  an  inflammation  of  the  deli- 
cate vascular  membrane  which  swells  and  enlarges  and 
pushes  the  tooth  slightly  from  the  socket.  The  peri- 
cementum is  the  tactile  organ  of  the  tooth,  and  when 
inflamed  it  is  extremely  tender  to  percussion.  The  dif- 
ference to  be  found  between  septic  and  non-septic  peri- 
cementitis will  generally  depend  upon  the  history  of  the 
operations  on  the  tooth,  as  to  the  treatment  and  filling 
of  the  root  canals.  There  is  no  pus  formation  in  the  non- 
septic  pericementitis.  When  percussion  is  applied,  there 
is  a  dull  sound;  and  we  find  a  deeper  color  in  the  gum 
tissue.2 

Acute  Septic  Pericementitis  or  Acute  Dento- 
Alveolar  Abscess 

The  septic  diseases  of  the  pericementum  are  almost 
invariably  the  result  of  infection  from  suppuration  and 
gangrene  of  the  pulp  or  that  from  the  oral  cavity,  through 

1  Buckley. 

2  Burchard. 


DENTAL  PAIN  47 

the  pulp  chambers  and  root  canals  of  dead  teeth.  The 
latter  cause  is  most  frequently  a  result  of  carelessness  of 
the  operator  in  forcing  septic  matter  into  the  apical  space 
with  a  broach.  It  is  very  questionable  whether  pyorrhea 
alveolaris  pockets  cause  this  condition,  by  their  proximity. 
The  writer  prefers  to  believe  this  supposed  condition  to 
be  an  extension  of  the  pyorrhea  alveolaris  itself.  Acute 
abscesses  are  prone  to  occur  under  the  above  conditions 
when  a  patient  "takes  cold." 

The  inflammatory  process  is  the  same  in  the  dento- 
alveolar  region  as  in  any  other  tissues  of  the  body,  the 
infecting  organisms  produce  the  same  condition  at  the 
apex  and  in  the  apical  tissues.  Hyperemia  follows  the 
primary  infection  and  sensation  in  the  tissue  is  altered  by 
the  resultant  pressure. 

Upon  tlit-  entrance  of  this  mailer  into  the  apical  tissues, 
and  the  further  process  of  inflammation,  the  pain  is  very 
ureal  because  of  the  abnormal  pressure  on  the  sensory 
nerves;  and  the  swelling  of  the  part  forces  the  tooth  from 
the  socket.  This  increases  the  pain  and  irritation,  by 
contact  with  the  opposite  teeth.  The  next  stage  is  the 
formation  of  pus  by  the  degeneration  of  the  apical 
tissues.  Throbbing  pains  which  are  extremely  depress- 
ing result  from  the  pressure  of  the  pus-irritation  and  the 
inflammation. 

The  next  process  is  the  exit  of  the  pus  through  the  tissue 
which  offers  the  least  resistance;  usually  through  the  outer 
alveolar  process,  the  thinnest  part.  The  pain  is  very 
severe  during  the  time  of  this  boring  of  the  pus  for  an 
exit;  but  when  it  has  accomplished  the  destruction  at 
the  point  of  advance,  the  pain  reduces,  the  soft  tissues 
offering  much  less  resistance  than  the  bone.  There  is  a 
great  difference  in  patients,  in  many  the  tissue  will  not 
give   way   so    readily.     Extremely    large    and    unsightly 


48  FIRST   AID   DENTISTRY 

swelling  results.  With  abscesses  on  the  upper  teeth,  the 
eye  on  the  side  affected  becomes  almost  closed  and  the 
cuticle  is  shiny  and  tight. 

In  some  cases  the  pus  burrows  through  the  bone  and 
out  through  the  gums  and  breaks  within  the  mouth,  with- 
out any  swelling  of  the  face.  Some  pus  tracts  will  not 
make  the  exit  in  the  mouth  but  will  wend  their  way  down 
the  neck  or  out  on  the  face.  In  many  cases,  the  point  of 
the  abscess  will  not  break  through  the  mucous  membrane 
in  the  mouth,  which  appears  to  be  tough  and  resistant. 

From  an  opening  being  made  by  lancing  these  abscesses 
will,  in  the  majority  of  cases,  freely  discharge  and  evacu- 
ate the  full  tract.  The  pressure  of  the  blood  system  will 
be  evidenced  by  the  spurts  of  pus  with  each  heart  beat. 
The  formation  of  abscesses  in  patients  suffering  from  sys- 
temic diseases  may  be  the  beginning  of  complications, 
causing  the  formation  of  necrosis  of  the  bones,  etc. 

Diagnosis 

In  the  beginning  of  an  acute  alveolar  abscess  the  pa- 
tient will  feel  an  uncomfortable  condition  at  the  apex  of 
the  tooth,  or  rather  in  the  deeper  gum  tissue  around  the 
tooth.  He  may  experience  reflex  pains  and  not  know 
which  tooth  is  aching,  but  in  the  majority  of  cases  pre- 
sented there  will  be  no  question,  the  pain  being  localized 
in  the  tooth  or  directly  at  its  apex.  There  is  usually  a 
smoky  dark  discoloration  noticed,  and  the  pressure  of  pus 
and  a  darkened  color  of  the  gum  tissue  over  the  roots  of 
the  tooth.  No  response  to  thermal  changes  will  be 
noticed.  The  tooth  will  usually  be  elongated  and  loose, 
contact  with  other  teeth  being  very  painful  and  sometimes 
impossible.  Percussion  or  tapping  a  tooth  in  this  con- 
dition is  only  useful  where  it  is  not  protruded  or  loose, 


DENTAL   PAIN 


49 


as  the  diagnosis  of  the  acute  abscess  will  be  fully  deter- 
mined by  the  above  observations. 


Chronic  Alveolar  Abscess 

A  chronic  alveolar  abscess  is,  as  the  name  implies,  a 
chronic  abscess  condition,  in  which  the  pus  contiunally 
forms  by  the  alternate  formation^and  breaking  down  of 
apical  tissues  and  granulations  with  the  expulsion  and 
drain  of  pus.  The  principal  cause  of  this  condition  is 
originally   the   acute   alveolar   abscess,   described   above, 


Fig.  16. — Chronic  dento-alveolar  abscess  one  root  of  upper,    left,    first 
molar.     Radiograph. — (Author's  practice.) 

and  the  causes  of  the  former  will  be  considered  the  same 
as  those  of  the  latter. 

There  are  two  kinds  of  chronic  abscesses:  those  without 
an  opening,  except  as  a  drain  may  form  through  the  root 
canals  of  the  tooth;  and  those  which  are  discharging 
through  a  sinus  or  fistula. 

The  first  class  may  drain  into  the  mouth  for  months  and 
not  give  the  patient  any  pain  or  annoyance,  because  the 
canal  of  the  tooth  offers  an  exit.  The  drain  is  natural 
and  has  no  resistance  to  its  discharge;  but  when  the  root 
canals  or  pulp-chambers  become  stopped  up  and  cut  off 
the  tract,  swelling  and  reaction  becomes  prominent. 


50  FIRST  AID   DENTISTRY 

The  chronic  abscess  is  generally  found  to  be  on  only  one 
root  of  a  multi-rooted  tooth,  all  three  roots  of  a  molar, 
for  instance,  will  not  be  affected.  (See  Fig.  No.  16, 
radiograph,  upper  first  molar.) 

The  tract  of  an  abscess  of  this  kind  is  lined  by  cicatricial 
tissue,  which  is  formed  in  the  abscess  cavity  and  lines  the 
tract  to  the  end  of  sinus,  generally  on  the  buccal  or  on  the 
outer  jaw  surfaces. 

The  tract  may  be  compared  to  a  blood-vessel,  as  the 
pus  will  lead  directly  from  the  central  sac  through  it  to 
the  opening,  the  mouth  of  which  may  not  be  directly 
opposite  the  tooth  affected.  It  may  course  down  the  sides 
of  the  bone  and  open  opposite  an  innocent  tooth.  The 
general  rule,  however,  is  to  open  over  the  diseased  tooth. 

The  pus  in  abscesses  of  the  upper  molars  and  bicuspids 
may,  however,  bore  into  the  Antrum  of  Highmore,  at  the 
points  where  the  bony  process  of  its  floor  is  thinner  and 
offers  the  least  resistance  to  the  exit  of  the  infection. 

In  the  lower  teeth,  gravitation  is  always  to  be  consid- 
ered. The  pus  may  bore  through  the  body  of  the  bone  and 
cut  on  the  face  or  chin.  An  impacted  tooth  may  be  the 
cause  of  a  chronic  abscess.  With  the  lower  wisdom  teeth 
this  is  a  common  cause,  the  fistula  here  nearly  always 
making  its  appearance  through  the  inner  plate  into  the 
mouth,  or  at  the  side  of  the  tooth  through  the  socket. 

So  much  pus  and  the  process  of  building  up  and  tearing 
down  of  the  new  tissue,  in  many  cases  causes  a  necrosis  of 
the  bone,  or  alveolar  process,  at  this  point.  It  may  form 
without  the  patient's  being  conscious  of  any  trouble, 
except  the  appearance  of  a  "gum  boil"  as  he  calls  the 
teat  of  the  fistula  which  recurrently  fills  and  breaks. 
The  complications  of  the  chronic  alveolar  abscess  demand 
attention  and  permanent  treatment  more  than  any  other 
tooth  affection. 


DENTAL  PAIN  5 1 

Diagnosis 

The  stopping  of  the  discharge  of  pus  through  the  teeth, 
will  be  very  difficult.  When  it  is  evacuated  in  treatment, 
it  will  probably  persist  and  appear  to  come  from  an  un- 
limited supply,  which  thus  aids  the  diagnosis  of  the  chronic 
condition  to  a  great  extent.  The  probe  will  pass  an  amaz- 
ing distance  through  the  external  opening  into  soft  tissue, 
without  any  apparent  resistance,  which  shows  the  presence 
of  destruction  of  the  apical  structure. 

The  diagnosis  of  the  chronic  dento-alveolar  abscess  is 
comparatively  easy.  When  the  patient  has  had  pain  in 
the  tooth  and  the  tract  points  into  near-by  tissue,  it  ap- 
pears and  discharges  by  one,  two  or  three  small  openings, 
very  close  together.  The  use  of  a  line  silver  probe  to 
hnd  the  direction  of  the  tract  and  tooth  affected  will 
serve  where  there  is  question. 

The  X-ray  will  serve  admirably  here  and  the  history  of 
the  tooth  as  to  treatment,  the  pulp  removed,  root  fillings, 
etc.,  will  aid  materially.  The  fact  that  it  carries  a  filling 
or  crown,  etc.,  or  has  been  treated,  roots  filled,  only  adds 
to  the  suspicion  that  it  is  the  tooth  affected. 


CHAPTER  VII 


THE  TREATMENT  OF  PULPITIS  (INFLAMMA- 
TION OF  THE  PULP) 

The  first  consideration  in  the  treatment  of  the  patient 
is  the  instruments,  their  care  and  use.  Figs.  17  and  18 
show  the  instruments  which  the  writer  believes  to  be  neces- 
sary in   the   treatment  of  emergency  cases.     A   mirror, 


■11  ■■  in  Jin  irf  11  nir  r  iflnnfffi 


Mirror 


Explorer 


Dressing 
pliers 


Right  and 
left  spoon 
excavators 


Fig.  17. 

dressing  pliers,  explorer,  chisels,  excavators,  broaches  and 
plastic  instruments. 

There  should  be  no  question  in  the  sterilization  of  these 
instruments,  they  should  be  boiled  in  water  a  sufficient 
length  of  time  and  brushed  clean,  with  the  exception  of  the 
mirror. Have  a  clean  glass  or  receptacle  for  a  10  per  cent. 

52 


00 


solution  of  formaldehyde,  with  a  small  amount  of  borax 
to  prevent  rust,  in  which  to  dip  these  instruments  and  to 
sterilize  the  mirror,  wiping  dry  with  a  clean  towel  before 
placing  in  the  mouth.  The  use  of  these  instruments  will 
be  explained  and  illustrated  in  the  following  treatments. 
When  a  patient  has  had  a  severe  toothache,  in  all 
probability  he  has  neglected  his  teeth.  Foul  odors  from 
fermenting  food  and  a  bad  taste  will  be  present  and  this 


Plastic 
instrument 


Fig.  i 8. 


is  where  we  must  make  the  sitting  agreeable.  A  warm, 
body  temperature  solution  of  one  of  the  following  anti- 
septic mouth  washes,  used  in  a  syringe,  will  be  found  to 
deodorize  and  stimulate  the  patient's  mouth.  He  will  feel 
grateful  and  it  will  be  more  pleasant  to  work  in  the 
region. 

Dobell's  solution,  50  per  cent,  in  hot  water,  or  5  per  cent, 
carbolic  acid,  with  a  few  drops  of  oil  of  wintergreen  or 
cassia,  dissolved  in  alcohol,  added  will  make  a  very  pleas- 
ant wash.  Listerine  is  fairly  good  used  in  this  manner. 
A  good  astringent  and  antiseptic  is  as  follows: 


54  FIRST  AID   DENTISTRY 

1$.    Boroglycerinse, 
Tinct.  krameriae, 

Tinct.  calenduale. 01 

Alcoholis aa  30  c.c. 

Sig. — One  or  two  teaspoonfuls  in  glass  of  water. 

It  has  been  said  that  the  way  to  stop  a  tooth  with  an 
exposed  pulp  from  aching,  is  to  take  it  in  out  of  the  wet. 
This  is  correct  and  must  be  borne  in  mind  in  sealing  the 
medicine  in  the  cavity. 

In  choosing  the  proper  drug  then,  we  must  find  one 
that  does  not  dissolve  easily  in  water.  For  this  reason 
cocaine  or  eucaine  and  other  drugs  requiring  a  solution  to 
carry  them  or  agents  that  are  freely  soluble  in  water, 
cannot  be  expected  to  keep  the  tooth  from  aching,  because 
they  wash  out,  although  they  will  relieve  temporarily. 
What  we  want  is  a  drug  that  has  anaesthetic  and  disin- 
fectant properties  and  is  sparingly  soluble  in  water. 

The  following  may  be  used,  preference  in  the  order 
named:  campho-phenique,  carbolic  acid,  eugenol  and 
oil  of  cloves.  There  are  many  others  but  this  number  will 
suffice,  since  the  emergency  case  will  contain  at  least  one 
of  the  above. 

The  pain  from  which  the  patient  is  suffering  having  been 
diagnosed  as  pulpitis  from  exposure  of  the  pulp;  the 
preparation  for  its  treatment  will  be  made.  The  operator 
must  be  cleanly  and  have  his  hands  free  from  dirt  or  infec- 
tion, beyond  doubt  in  the  patient's  or  his  own  mind. 
Open  the  mouth  gently,  use  a  warm  solution  of  a  pleasant 
mouth  wash  forced  through  a  syringe  and  have  the  parts 
as  clean  as  possible.  Place  the  mirror  over  the  tooth  and 
locate  the  cavity,  then  with  a  small  pledget  of  cotton  wipe 
the  tooth  dry  as  possible,  observe  the  food  particles  which 
may  be  present  and  with  a  warm  spray  flush  them  from 
the  cavity.     Take  two  cotton  rolls  about  the  size  of  the 


THE   TREATMENT   OF   PULPITIS 


55 


second  finger;  place  one  on  the  outer  side,  between  the 
lips  or  cheek  and  the  gums,  the  other  down  well  between 
the  tongue  and  the  gum  margins  and  hold  in  place  by 
the  mirror,  as  shown  in  Fig.  19.  For  the  upper  teeth, 
only  one  roll  will  be  necessary,  placed  on  the  outside  of 


Fig.  19. — Method  of  excluding  saliva  while  placing  dressing  in  a  cavity. 
Rolls  placed  on  either  side  of  tooth  and  held  in  place  by  mirror  while 
the  cavity  is  dried. 


the  teeth,  it  will  be  held  in  place  by  the  cheek  or  buccal 
muscles. 

Dry  the  cavity  gently  with  cotton,  and  with  an  explorer 
ascertain  the  point  of  exposure.  Do  not  force  the  explorer 
into  the  pulp.     With  a  spoon  excavator,  shown  in  Fig. 


56 


FIRST  AID  DENTISTRY 


20,   remove   the   leathery   decay   as   much   as   possible, 
drawing  the  instrument  away  from  the  pulp-chamber. 

Dry  the  tooth  again  with  a  loose  pledget  of  cotton. 
Prepare  all  the  following  pledgets  of  cotton  rolled  to  the 
proper  size  and  have  the  bottles  containing  the  drugs  to  be 
used,  open  on  a  table  where  they  are  within  easy  reach. 
Saturate  the  first  and  smallest  pledget  in  one  of  the  above- 


Fig.  20. — Removal  of  decay  with  spoon  excavator. 


mentioned  remedies  and  place  in  the  cavity  as  shown  in 
Fig.  21.  Then  without  removing  the  mirror,  cover 
this  with  a  slightly  larger,  loose  pledget,  then  dip  the 
larger  one,  which  is  slightly  smaller  than  the  cavity,  in 
sandarac  varnish  or  vaseline  and  place  over  the  cavity. 
Take  the  first  finger  of  the  right  hand  and  after  dipping  it 
into  warm  water,  gently  press  the  varnished  or  vaselined 
cotton  as  is  shown  in  Fig.  22.     Where  the  pulp  is  nearly 


THE   TREATMENT   OF   PULPITIS 


57 


exposed,  this  will  be  found  more  desirable  than  the  use 
of  the  gutta-percha  stopping,  because  of  the  difficulty 
in  avoiding  pressure,  which  will  cause  as  much  or  more  pain 
than  before  treating.  Creasote  should  not  be  used  in  these 
teeth  because  it  is  supposed  to  be  lacking  in  the  properties 
desired. 


Fig.  21. — Placing  medicine  on  pellet  of  cotton  in  the  cavity  of  the  tooth, 
protecting  lips  by  finger  of  hand  holding  tweezers. 


In  case  the  tooth  has  been  aching  for  two  days  or  more 
you  will  expect  to  find  a  pulp  congested  with  blood.  In 
this  case  puncture  the  outer  membrane  slightly  and  permit 
the  blood  to  ooze  out.  The  cotton  rolls  and  mirror  being 
placed  as  described  above,  the  bleeding  can  be  permitted 


58  FIRST  AID   DENTISTRY 

and  the  blood  absorbed  with  cotton  pledgets  and  then  one 
of  the  above  treatments  applied. 

Should  the  cavity  be  located  between  the  teeth  and  the 
enamel  be  standing,  but  undermined,  it  will  be  neces- 
sary to  take  a  broad  chisel,  as  shown  in  Fig.  23  and 
break  down  this  covering,  so  good  access  can  be  had  to 
the  cavity.     Care  must  be  taken  to  prevent  the  slipping 


Fig.  22. — The  tooth  treated  and  medicated  cotton  covered  by  Sandarac- 

cotton. 

of  the  instrument  into  the  cavity  by  the  guard  of  the 
second  ringer  on  the  surface  of  the  tooth  as  is  shown  in 
Fig.  20. 

In  case  the  exposure  is  not  complete,  the  tooth  should  be 
treated  in  the  above  manner  and  the  surfaceof  the  cavity 


THE   TREATMENT   OF   PULPITIS 


59 


seared  with  one  of  the  drugs  given,  as  the  effect  of  the  drug 
will  be  carried  through  the  dentinal  tubules  to  the  pulp 
tissues.     See  Fig.  15  (Brief  Dental  Anatomy). 

In  cases  where  there  is  a  filling,  either  firm  or  partially 
loose,  difficulty  will  be  experienced  in  removing  it  without 
a  dental  engine  drill,  but  this  can  be  done  with  chisels,  in 


Fig.  23. — Method  and  position  in  breaking  down  enamel  with  a  chisel, 
showing  fulcrum  and  guard  of  second  finger. 


the  same  manner  as  described  above  in  breaking  down  the 
enamel.  The  margins  being  broken,  the  filling  is  pried  and 
lifted  out  with  the  spoon  excavators,  and  the  treatment 
applied  as  above. 

When  pain  presents  from  mechanical  abrasion,  the 
enamel  is  worn  away  and  the  dentine  is  exposed  or  the 
ends  of  the  dentinal  tubules  are  exposed  and  the  inter- 
tubular  substance  transmits  irritation  to  the  pulp. 


60  FIRST  AID   DENTISTRY 

Place  cotton  rolls  to  protect  the  gums  and  with  a  pledget 
of  cotton  saturated  in  a  solution  made  by  dissolving  a 
small  crystal  of  silver  nitrate  in  a  drop  or  two  of  water, 
sear  the  part.  Keep  the  mouth  open  a  few  minutes,  then 
remove  any  surplus  with  a  cotton  pledget. 


CHAPTER  VIII 

THE  TREATMENT  OF  PUTRESCENT  PULPS 
AND  NON-SEPTIC  PERICEMENTITIS 

The  aim  of  the  dental  operator  in  treating  putrescent 
pulps  is  to  afford  an  escape  for  gases  and  use  a  drug  which 
will  destroy  or  change  them  into  a  solid  or  liquid  and  pre- 
vent pressure.  Buckley  gives  three  important  factors 
which  must  be  accomplished,  viz.:  i.  Establish  asepsis. 
2.  Prevent  recurring  sepsis.  3.  Preserve  and  restore  the 
color  of  the  teeth.  The  course  to  be  pursued  by  the  opera- 
tor in  treating  emergency  cases,  will  conform  to  the  above, 
except  in  the  last  point,  the  third  factor  "restore  color," 
which  will  be  left  to  the  dental  surgeon,  not  being  con- 
sidered an  emergency. 

The  mouth  should  be  treated  in  the  same  manner  as 
described  above  in  preparation,  by  flushing  it  out  and 
cleaning  the  teeth.  It  is  proper  to  apply  the  rubber  dam 
over  the  tooth  and  adjoining  teeth  and  disinfect  with 
formalin  solution,  described  in  the  preceding  chapter  for 
use,  in  dipping  instruments,  but  this  will  not  usually  be 
attempted  by  the  operator  in  emergency  cases. 

The  cotton  rolls  will  be  used  as  previously  show'n  and 
described  and  the  tooth  will  be  washed  with  a  large  pledget 
of  cotton  saturated  with  alcohol.  The  opening  into  the 
pulp-chamber  will  now  be  made  and  the  chisels  described 
in  the  foregoing  chapter  will  be  used,  in  case  the  cavity 
has  been  filled  and  access  cannot  be  made  by  the  use  of  the 
excavators. 

In  cases  where  the  tooth  is  sound  and  has  no  weak  mar- 

6i 


62 


FIRST  AID   DENTISTRY 


gins  it  will  be  almost  impossible  to  make  an  opening  with- 
out a  dental  engine  burr,  but  these  cases  are  infrequent. 

The  cavity  being  opened,  the  pulp-chamber  should  now 
be  entered  and  this  can  easily  be  done,  where  we  have 
access,  with  a  spoon  excavator.  The  opening  should  be 
large. 

The  chamber  should  be  enlarged  sufficiently  for  the 
mouth  of  the  canals,  as  the  tooth  may  be  single  or  multi- 


Fig.  24.- 


-Putrescent  pulp,  showing  manner  of  opening  root  canal  mouth 
with  a  broach. 


rooted,  to  be  opened  by  the  point  of  the  broach.  Fig.  24. 
Do  not  run  the  instrument  through  the  canal,  merely 
place  it  in  the  opening  to  be  sure  that  the  mouth  is  not 
closed- 


THE   TREATMENT   OF   PUTRESCENT  PULPS  63 

Take  a  small  pledget  of  cotton  and  saturate  it  in  the 
following  remedy:  Cresol  and  formaldehyde,  of  each  equal 
parts.  Touch  it  to  a  towel  to  remove  the  excess  of  the 
liquid  and  place  in  the  pulp-chamber  in  the  same  manner 
as  given  in  the  previous  chapter.  A  loose  pledget  of  cot- 
ton saturated  in  an  oxyphosphate  cement  filling,  mixed 
very  thin  should  be  used  to  seal  the  cavity.  This  will  not 
be  convenient  in  many  cases  and  a  sandarac  varnish  dress- 
ing may  be  placed  over  the  cavity.  It  is  better  not  to 
seal  this  cavity  with  gutta-percha  stopping,  because  of 
the  difficulty  in  avoiding  pressure  and  forcing  the  remedy 
through  the  canals.  Such  an  accident  will  cause  a  very 
painful  toothache  for  which  nothing  can  be  done,  except 
to  force  warm  antiseptic  water  into  the  chamber,  in  the 
hopes  of  diluting  the  drugs.  However,  it  will  generally 
not  ache  more  than  half  an  hour. 

This  treatment  will  be  sufficient  for  three  or  four  days, 
and  if  the  patient  requires  further  treatment  the  dressing 
can  be  removed  and  in  the  same  manner  the  tooth  pre- 
pared for  re-dressing,  as  above.  The  canals  may  now  be 
cleaned  with  a  small  broach  and  the  treatment  again 
sealed,  this  time  with  the  gutta-percha  stopping.  Smooth 
this  with  a  pledget  of  cotton  saturated  in  chloroform. 

Dr.  Buckley  is  responsible  for  the  perfection  of  this  ex- 
cellent cresol  and  formaldehyde  treatment,  the  chemistry 
of  which  makes  it  the  rational  treatment:  The  gases  am- 
monia and  hydrogen  sulphid  of  putrescent  pulp  uniting 
with  formaldehyde,  urotropin  and  methyl  alcohol  and 
sulphur,  are  formed.  Basic  ptomaines,  unite  with  for- 
maldehyde forming  inodorous  compounds.  The  cresol 
(tricresol)  is  a  disinfectant  and  saponifies  the  fats.  This 
treatment  is  used  almost  universally  by  dentists  and  has 
eliminated  to  a  very  great  extent  the  older  and  inefficient 
methods  of  treating  this  condition. 


64  first  aid  dentistry 

Non-septic  Pericementitis 

In  the  emergency  treatment  of  this  condition,  the  drug 
irritants  which  have  been  used  in  the  pulp  extirpation, 
devitalization  and  preparation  for  root  filling  will  have 
had  their  effect  and  this  cannot  be  removed,  so  relief  must 
be  administered.  Mechanical  irritants,  however,  such  as 
ill-fitting  plates,  crowns,  bridges,  fillings,  etc.  (except  root- 
canal  fillings),  can  be  removed.  It  is  ill  advised  for  any 
except  the  dental  surgeon  to  attempt  to  remove  a  root- 
canal  filling.  Crowns  or  fillings  that  are  left  too  high 
may  be  ground  down  to  relieve  the  condition. 

Immediate  relief  must  be  accomplished  by  the  applica- 
tion of  drugs  and  remedies.  When  a  tooth  is  very  sore 
and  has  been  diagnosed  as  non-septic  pericementitis,  one 
of  the  ways  to  relieve  it  temporarily  is  to  place  a  silk  dental 
floss  around  it  and  slightly  pull  from  the  socket.  The 
slight  pulling  alters  the  tension  in  the  peridental  mem- 
brane. It  is  then  a  matter  of  counter-irritation.  Wipe 
the  gums  as  dry  as  possible  around  the  tooth.  Take  a 
pledget  of  cotton  soaked  in  tincture  of  iodine  tincture  of 
aconite,  and  chloroform,  equal  parts,  and  paint  this  dry 
surface,  holding  the  lips  and  cheeks  away  until  the  evap- 
oration ensues.  Blowing  the  surface  with  a  chip  blower 
also  adds  to  the  effect. 

The  patient  may  be  given  a  small  amount  of  this  mixture 
to  paint  over  the  parts,  and  carefully  instructed  as  to  the 
quantity  necessary,  etc.  Another  counter-irritant  recom- 
mended by  Buckley  for  this  is  a  split  raisin,  first  soaked  in 
hot  water  and  dusted  with  red  pepper,  applied  to  the  gums 
over  the  tooth.  Another  remedy  for  the  patient  to  use 
is  the  holding  of  water,  as  hot  as  can  be  borne,  around  the 
tooth.  A  foot  bath,  the  patient  holding  his  feet  for  fifteen 
or  thirty  minutes,  in  very  hot  water,  is  an  excellent  remedy. 


CHAPTER  IX 
TREATMENT  OF  ABSCESS 

Acute  Alveolar  Abscess. — A  knowledge  of  the  pathology 
is  more  necessary  in  treating  this  condition  than  any  other 
we  find.  The  treatment  of  acute  alveolar  abscesses  should 
be  abortive  in  the  first  stage  of  the  inflammation  and  pus 
formation,  and  in  the  second  stage  up  to  the  time  the  pus 
perforates  through  the  alveolar  process. 

The  local  treatment  is  to  flush  clean  and  sterilize  the 
patient's  mouth  with  the  washes  advised  before;  clean 
and  dry  the  part  and  place  the  cotton  rolls  as  previously 
described.  Enlarge  the  cavity  in  the  tooth  until  the  pulp- 
chamber  is  opened  and  with  the  excavator  remove  the 
debris  in  this  part  until  the  root  canals  can  be  entered. 
Take  a  broach  and  enter  these  canals  (Fig.  24).  Spon- 
taneous relief  from  the  pain  will  be  noticed  when  the  pus 
begins  to  make  its  appearance  into  the  cavity.  An  as- 
tonishing amount  of  pus  frequently  exudes  from  the  apex, 
five  or  six  drops  at  a  time  rushing  from  the  canal.  Let 
this  continue  to  drain.  At  the  first  sitting,  place  a  pledget 
of  cotton,  saturated  in  formalin  and  cresol  solution  (the 
excess  being  removed  by  touching  to  a  towel)  in  the  bot- 
tom of  the  cavity;  cover  this  with  a  loose  dressing  of 
cotton,  soaked  in  sandarac  varnish  or  vaseline. 

At  this  stage  a  good  counter-irritant  may  be  placed  over 
the  gums  around  the  apex  (tincture  of  iodine,  tincture  of 
aconite  and  chloroform,  as  given  in  the  preceding  chap- 
ters). The  abortive  treatment  should  be  instituted  for 
this  stage,  a  good  saline  cathartic,  as  Epsom's  salts,  or 

6s 


66  FIRST  AID  DENTISTRY 

magnesium  citrate  will  prevent  an  accumulation  of  blood 
in  the  part.     An  excellent  alterative  can  be  given,  viz.,1 

1$.    Potassii  iodii 6  gms. 

Syrupus  sarsaparilla  comp 90  c.c. 

Sig. — Take  a  teaspoonful  in  water  after  meals. 

In  most  cases  the  pain  will  subside  after  the  tooth  has 
been  treated  and  the  pus  evacuated  from  the  cavity,  but 
when  the  patient  is  nervous  and  has  lost  sleep  a  good  drug 
to  be  administered  is  acetanilid,  which  may  be  given  in 
the  following  form:2 

1$.    Pulveris  acetanalidum  comp 0.5  gm. 

Syrupus  simplex 150  c.c. 

Spiritus  frumentii q.  s.  ad    90.0  c.c. 

Sig. — Take  half  at  once  and  remainder  in  two  hours  if  necessary. 

When  it  has  been  decided  that  pus  has  formed  and  is 
external  to  the  alveolar  process,  which  can  be  determined 
by  pressing  the  finger  gently  over  the  part,  the  treatment 
of  the  tooth  proper  should  be  the  same  and  the  abortive 
treatment  will  be  altered  by  the  judgment  of  its  necessity. 
The  counter-irritation  should  not  be  applied  to  this  outer 
surface,  under  any  circumstances,  at  this  time,  for  fear  of 
driving  the  pus  toward  the  inner  wall  and  into  the  Antrum 
of  Highmore.  Take  a  lancet,  lift  the  lips  and  hold  clear 
of  the  operation,  touch  the  point  of  the  abscess  with  phenol 
on  the  instrument  and  then  force  the  bistory  into  the  tis- 
sue and  force  it  deep,  until  it  touches  the  alveolar  process 
plate ;  move  it  around  in  the  region  until  the  end  finds  the 
point  of  perforation.  When  this  has  been  drained  and  all 
the  pus  is  forced  out  that  can  be  at  this  sitting,  take  a 
small  bundle  of  cotton  fibers,  roll  very  tight,  dip  in  phenol 
and  with  a  pair  of  tweezers  force  to  the  bottom  of  the  tract 

1  Buckley. 

2  Harlan  lectures. 


TREATMENT   OP    VBSl  67 

and  remove.  This  will  take  the  soreness  out  of  the  li 
and  cauterize  the  opening  for  subsequent  escape  of  pus. 
The  patient  should  be  directed  to  wash  his  mouth  fre- 
quently with  one  of  the  washes  given  before  and  holding 
some  of  the  solution  in  his  mouth,  to  gently  massage  the 
swollen  part  of  the  face. 

The  practice  of  painting  the  swollen  surfaces  outside 
the  face  with  tincture  of  iodine  is  good,  but  it  is  unsightly 
and  the  swelling  will  generally  go  down  in  twenty-four  to 
forty-eight  hours  after  the  first  treatment.  The  old 
method  of  poulticing  on  the  outside  of  the  face  is  absolutely 
uncalled  for  and  criminal. 

Chronic  Alveolar  Abscesses 

Chronic  abscesses,  without  sinus:  The  chronic  abscesses 
are,  unfortunately  for  the  patient,  not  so  painful  and 
therefore  demanding  emergency  treatment. 

The  treatment  of  the  chronic  abscesses,  without  fistula 
is  different  somewhat  from  the  procedure  in  the  acute 
abscess,  in  that  the  apical  opening  is  entered  freely  and 
the  contents  of  the  socket  stirred  to  forcible  expulsion. 
The  same  method  of  sterilizing  the  mouth  and  the  use  of 
the  cotton  rolls  and  opening  the  cavity  will  be  followed  in 
this  case. 

When  the  canal  is  opened,  there  is  already  a  pus  sac  at 
the  apex  and  the  broach  may  be  forced  through  into  it. 
Pressure  may  be  applied  over  this  apical  part  and  the  pus 
forced  through  the  canals.  These  are  now  cleaned  and  a 
loose  pledget  of  cotton,  dipped  into  phenol,  placed  in  the 
cavity  and  covered  with  vaselined  cotton.  The  next 
sitting,  the  cotton  will  be  removed  and  will  probably  Be 
saturated  with  pus,  which  has  formed  since  the  first  sitting. 
Drain  again,  as  before  and  then  place  a  pledget  of  cotton 


68 


FIRST   AID   DENTISTRY 


saturated  with  the  formalin  and  cresol  solution  into  these 
canals  and  seal  as  tightly  as  possible,  with  sandarac 
varnish  or  gutta-percha  stopping.     Remove  and  replace 


Fig.  25. — Chronic  dento-alveolar  abscess,  with  perforation  of  the 
root  and  subsequent  forcing  of  septic  matter  with  gutta-percha  through 
the  opening.     Three  years'  duration.     Radiograph. — (Author's  practice.) 

this  treatment  in  two  or  three  days,  if  further  attention  is 
demanded. 

Chronic  abscesses  may  present  for  emergency  treatment, 


Fig.  26. — Radiograph  of  case,  one  week  after  operation  and  filling  pocket 
with  bismuth  paste. — (Author's  practice.) 

which  are  the  result  of  septic  matter  being  forced  through 
a  perforated  root,  as  Fig.  25.  In  the  treatment  of  this 
case,   an  opening  for  drainage  was   made   through  the 


TREATMENT   OF  ABSCESS  69 

alveolar  process,  to  the  point  where  the  foreign  substance 
protruded,  this  smoothed  down  and  the  part  flushed  out 
and  filled  with  bismuth  paste.  The  second  picture,  Fig. 
26,  was  taken  one  week  after  the  operation. 

Chronic  Alveolar  Abscess   with  Fistula 

The  treatment  of  chronic  alveolar  abscesses  with  fistula 
is  one  which  will  not  generally  demand  an  urgent  emer- 
gency treatment,  because  the  opening  is  present  and  the 
continual  drain  eliminates  the  pain.     When  one  of  these 


Fig.  27. — Chronic  abscess,  upper  right  bicuspid. — (Author's  practice.) 

abscesses  is  seen  to  be  draining  on  the  outer  surface  of  the 
face,  an  emergency  is  certainly  considered  to  exist. 

The  extraction  of  a  tooth  which  has  a  tract  opening  on 
the  face  should  be  delayed  until  the  scar  is  healed  over. 
This  may  be  accomplished  by  opening  the  tract  inside  the 
mouth,  severing  it  between  the  point  that  is  bound  down 
and  the  exit  through  the  alveolar  process  on  the  inside  and 
turning  the  drain  into  the  oral  cavity.  Wait  until  the 
outer  severed  portion  of  the  tract  and  scar  are  healed  and 
filled  in,  and  then  extract  or  treat  as  desired. 

The  question  of  extracting  teeth  when  there  is  an  abscess 


7o 


FIRST  AID   DENTISTRY 


swelling  in  the  mouth  is  a  doubtful  one,  but  the  writer 
believes  that  this  should  not  be  considered  dangerous  or 
wrong,  as  the  pus  in  the  abscess  will  drain  readily  and  he 
does  not  believe  a  secondary  infection  occurs  if  the  mouth 
is  properly  treated  and  cleaned. 

The  aim  in  treating  chronic  alveolar  abscesses  with 
fistula,  is  to  irrigate  the  tract  from  the  opening  in  the  cavity 
and  the  root  canals,  by  forcing  a  light  antiseptic  bland 
solution  through  to  the  external  opening  and  then  place  a 
dressing  of  formo-cresol  solution  in  the  canals  for  a  day  or 
two.     The  dental  surgeon  will  burn  this  tract  to  its  ex- 


Fig.  28. — Chronic    dento-alveolar    abscess,    lower    right,    third    molar. 
Radiograph. — (^4  uthor's  practice.) 


tremity  with  phenosulphuric  acid  or  phenol  and  fill  the 
root  canals.  The  emergency  treatment  is  to  give  relief 
and  prevent  any  complications  by  making  a  good-sized 
opening  of  the  fistula  for  the  drain  of  the  pus  and  placing 
a  pledget  of  cotton,  rolled  on  a  broach  into  the  canals,  and 
to  endeavor  to  hermetically  seal  the  cavity. 

To  apply  cotton  in  this  way,  hold  a  few  fibers  of  cotton 
between  the  thumb  and  finger  of  the  left  hand,  place  the 
end  of  the  broach  in  this  and  twist,  holding  the  ends  of 
the  cotton  with  the  same  finger  of  the  right  hand.  Dip  it 
in  the  solution,  place  in  the  canal  and  holding  the  cotton 


TREATMENT    OF   ABSCESS  7 1 

in  place  with  the  beaks  of  a  pair  of  dressing  pliers  on  either 
side,  withdraw  the  broach. 

This  will  be  sufficient  to  meet  the  demands  of  emergency 
treatment,  in  chronic  cases,  the  completion  of  which 
should  not  be  delayed  until  a  dental  surgeon  is  available. 


CHAPTER  X 

NEURALGIA 

When  the  condition  present  is  evidently  not  one  de- 
scribed in  the  chapter  on  dental  pain  and  a  cure  cannot 
be  affected  by  the  methods  given  for  affected  teeth,  we 
look  to  a  solution  of  the  dilemma  in  Neuralgia. 

Neuralgia  (Nerve  Pain) 

Neuralgia  is  a  manifestation  of  the  disorder  produced 
by  overexcitation  of  the  sensory  nerves  or  by  perverted 
function.  Reflex  pain  is  a  pain  experienced  at  some  point 
other  than  that  of  its  origin.  Neuralgia  is  described  as 
a  stinging,  severe,  paroxysmal  pain  along  the  course  or 
part  of  the  course  of  a  nerve  and  in  the  area  of  its  dis- 
tribution. Neuralgia  occurs  in  many  organs  and  parts 
of  the  body  and  except  for  those  reflected  from  dental 
sources  will  be  treated  by  the  general  practitioner. 

The  dental  operator  is  called  upon  to  treat  chiefly 
those  which  appear  in  the  region  of  distribution  or  along 
the  course  of  the  fifth  cranial  nerve.  These  are  called 
tri-facial,  facial  and  trigminal  neuralgia. 

Marshall1  gives  a  very  comprehensive  and  complete 
idea  of  •  causes  of  neuralgia,  in  the  following. 

"The  conditions  which  are  productive  of  neuralgia  are 
many  and  varied  and  consist  chiefly  of  diseases  which 
lower  the  vital  powers  of  the  system,  such  as  anemia,  or 

1  "Injuries  and  Surgical  Diseases  of  the  Face,  Mouth  and  Jaws." 

72 


NEURALGIA 


73 


those  which  interfere  with  such  functions  as  the  circula- 
tion, respiration,  digestion,  assimilation,  secretion  and 
elimination;  the  presence  in  the  system  of  abnormal  sub- 
stances as  in  gout,  rheumatism,  diabetes,  malaria, 
nephritis,  chronic  pyemia,  syphilis  and  metallic  poison- 
ing, local  conditions  which  cause  reflex  peripheral  irri- 
tation, such  as  diseases  of  the  teeth,  eye,  ears,  stomach, 
uterus  and  ovaries;  chronic  inflammation  of  the  nerve  or 
its  sheath,  pressure  from  abnormal  growths,  within  the 
bony  canal  through  which  the  nerve  trunk  passes,  or 
pressure  from  tumors  and  localized  anemia  or  congestion 
of  nerves  or  nerve  centers." 

Facial  Neuralgia  for  consideration  in  this  chapter  will 
be  divided  into   two  classes:   those  arising  from  dental 


Fig. 


29. — Impacted  third  molar.     A  hidden  cause  of  facial  neuralgia. 
Radiograph. — (.4  uthor's  practice.) 


sources  and  those  arising  from  other  than  dental  sources. 
In  the  first  class  we  find: 

Exposed  dentine  around  the  necks  of  the  teeth,  as  a 
result  of  abrasion,  neuralgic  pains  may  be  produced  by 
merely  touching  these  surfaces  with  an  instrument,  or 
even  with  the  finger  nail. 

Pulpitis.— The  pain  may  be  referred  to  another  part  or 
area  than  its  origin. 

Pulp  nodules,  or  pulp  stones  and  secondary  dentine  af- 
fections outnumber  all  other  conditions  as  causes. 


74  FIRST  AID   DENTISTRY 

Pericementitis. — Generally  the  pain  is  located  over  the 
affected  tooth,  yet  it  may  not  be  and  the  pain  be  referred 
from  this  point. 

Cementosis. — This  is  one  of  the  more  common  causes 
of  facial  neuralgia,  because  of  the  pressure  of  the  growth 
against  the  nerve  trunk  or  sheath. 

Deposits. — Calcic  deposits  on  the  roots  of  teeth. 

Impacted  Teeth. — Maleruption  of  the  lower  third  molars 
is  the  most  frequent  example  of  neuralgia  from  this  source 
because  of  its  anatomical  relation  with  the  inferior  dental 
nerve  which  courses  the  inner  part  of  the  maxillary  bone. 
Fig.  29  shows  a  case  of  Neuralgia,  which  ceased  upon  ex- 
traction. From  this  source,  however,  the  pain  will  gen- 
erally be  localized  in  the  part. 

Burchard  and  Inglis  state  that  "an  equivalent  of  im- 
paction in  which  dental  irritation  may  be  the  source  of 
reflex  neuralgia,  is  when  the  teeth  are  crowded  or  jammed 
into  arches  too  small  for  their  accommodation."  Deaf- 
ness, suppurative  otitis  media,  disturbances  of  the  eye, 
temporary  blindness,  ovarian  and  uterine  neuralgia, 
sciatica,  pains  in  the  knee,  toes,  fingers,  have  been  traced 
to  dental  irritation. 

Those  cases  which  present  neuralgia  from  other  than 
dental  sources  are  just  the  opposite  of  the  above,  the  pain 
definitely  located  or  indefinitely  located  in  a  normal  tooth 
referred  from  some  other  source. 

The  condition  in  which  this  occurs  are  malaria,  gout, 
syphilis,  diseases  of  the  brain,  kidneys,  uterus,  bladder, 
disorders  in  pregnancy,  diseases  of  the  fifth  cranial  nerve, 
constipation  and  la-grippe. 

The  paramount  point  in  neuralgia  is  to  find  the  cause 
and  make  the  proper  diagnosis.     The  X-ray  in  many 


NEURALGIA  75 

cases,  is  the  only  method  by  which  we  may  discover  an 
irritating  cause. 

The  cause  found,  the  treatment  is  to  remove  it  and 
should  it  be  a  tooth,  diagnose  the  condition  and  treatment 
for  this  as  described  in  previous  chapters.  Do  not  ex- 
tract the  tooth  unless  deemed  absolutely  necessary  for 
relief. 

Local  application  of  drugs  which  act  upon  the  sensory 
nerve  ending  will  be  used  and  Buckley's  dental  liniment 
which  follows,  will  give  excellent  results. 

I}.    Mentholis 1.3  gms. 

Chloroform 6.0  c.c. 

Tinct.  aconite 3°-°  c.c. 

Sig. — Paint  over  the  area  affected. 

Another  liniment  recommended  by  Buckley: 

1$.    Mentholis 2.0  gms. 

Alcoholis, 

Aetheris aa  24.00  c.c. 

Chloroformi 90 .  00  c.c. 

Sig. — Apply  by  vigorous  rubbing  or  massage  over  the  area  of 
distribution  of  the  affected  nerves  or  along  its  course. 

In  many  cases  where  pain  in  the  upper  teeth  is  caused 
by  abscessed  teeth  or  affections  of  the  peridental  mem- 
brane, the  following  may  be  used  with  wonderful  results, 
stopping  the  pain  almost  instantly.1 

]$.    Alcoholis 

Aquae aa  30.00  c.c. 

Sig. — Use  as  a  spray  well  back  in  the  nostril  of  the  side  affected. 
Repeat  as  often  as  necessary. 

When  general  medicinal  treatment  is  demanded  for  cor- 
rection of  the  constitutional  disorder  or  alteration  of  treat- 
1  Buckley. 


76  "FIRST  AID   DENTISTRY 

ment  necessary,  the  physician  in  charge  will  make  these 
changes.  Dentists  have  kept  patients  suffering  for  some 
unnecessary  length  of  time  when  searching  for  a  cause  in 
the  mouth  when  it  was  a  general  or  constitutional  condi- 
tion, and  doctors,  just  the  same,  have  treated  patients  for 
months  without  result,  until  the  dentist  removed  or 
treated  the  offending  teeth. 

While  an  operator  is  searching  for  a  hidden  cause  it  is 
his  duty  to  administer  hypnotic  or  general  anodyne  or 
analgesic  and  the  prescriptions  of  some  of  the  best  in 
writer's  experience  follow: 

1$.    Pulveris  acetanilidum  comp gr.  xx  (1.3  gms.) 

Fiat  chartulae  no.  iv. 
Sig. — Take  one  powder  every  hour  until  two  or  three  are  taken, 
if  not  relieved  after  two  hours,  take  the  remaining  one  or  two. 

The  use  of  phenacetine  is  very  good  in  these  cases, 
combined  with  codeine  sulphate  or  salophen. 

1$.    Acetaphenacetinae, 

Salophen aa  gr.  xx  (1 . 3  gms.) 

Codienae  sulphatis .' gr.  i     (0.6  gms.) 

Fiat  chartulae  no.  iv. 

Sig. — Take  one  powder  every  two  hours. 

Neuralgia  cases  will  be  very  materially  aided  by  the 
following  prescription  which  is  simple  and  efficient. 

1$.    Acetanilidum gr.  vii  (o.  5  gms.) 

Syrupi  simplex fig  ss  (15.0  c.c.) 

Spiritus  frumentii qs.  ad.     fig       (90  c.c.) 

Sig. — Take  one-half  at  once  and  the  remainder  in  two  hours. 

When  these  remedies  will  not  suffice  and  the  patient 
is  in  such  a  condition  to  justify  the  last  resort,  the  use  of 
morphine  will  meet  the  demand.  Prescription  should  not 
be  given.     A  dose  of  1/8  gr.  (0.008  gm.)  may  be  given 


NEURALGIA  77 

by  the  stomach,  repeated  in  one-half  or  one  hour  and  the 
patient  given  one  more  tablet  to  take  at  home  if  necessary. 
This  is  the  conservative  amount  that  the  patient  should 
take  in  emergency  cases.  The  patient  should  be  given  a 
good  cathartic,  always;  and  if  the  conditions  persist  a  hot 
foot  bath,  as  advised  before,  will  aid  in  the  relief. 


CHAPTER  XI 
PYORRHEA  ALVEOLARIS 

This  is  an  acute  or  chronic  inflammatory  process  which 
includes  the  following  features : 

A  molecular  necrosis  of  the  peridental  membrane  (organ 
of  attachment  of  the  tooth  in  the  socket).  See  Fig.  15, 
Chapter  V. 

Atrophy  of  the  alveolar  walls. 

Hyperemia  of  the  gums. 

Pus  (generally  at  some  stage)  oozing  out  from  around 
the  necks  of  the  teeth. 


Fig.   30. — Pyorrhea    alveolaris.     Radiograph. — {Author's    practice.) 

Calcic  deposits  on  the  roots  of  the  teeth. 
Looseness  and  falling  out  of  the  teeth. 

This  disease  is  as  old  as  man;  people  of  all  races,  all 
stations  and  climates  and  time  and  modes  of  life  have 
suffered  from  it. 

It  has  been  studied  exhaustively  since  the  year  1746 
when  Fauchard1  published  a  description  of  it  and  from 

1  "The  American  Text-book  on  Operative  Dentistry.  " 

78 


PYORRHEA   ALVEOLARIS  79 

that  time  to  this,  many  able  men  have  occupied  their 
time  and  thoughts  seeking  satisfactory  explanation  of  its 
phenomena. 

It  is  the  most  named  disease  in  medical  science.  Each 
writer  having  observed  some  particular  symptom,  which 
was  paramount  in  his  observation,  made  a  title  which 
conveyed  his  idea. 

The  various  titles  are  therefore  descriptive  of  symp- 
toms or  stages  of  this  condition.  Among  the  more  com- 
mon titles  which  are  or  have  been  in  use  are:  Pyorrhea 
alveolaris,  interstitial  gingivitis,  Riggs  disease,  calcic  in- 
flammation, hematogenic  calcic  pericementitis,  gouty  peri- 
cementitis. There  are  practically  two  schools  regarding 
this  condition,  one  contending  a  local  and  the  other  a 
general  constitutional  etiology. 

The  local  adherents  cling  to  the  following  conditions  as 
the  causative  elements;  viz.,  subgingival  deposits  of  calculi, 
acute  inflammation  of  the  mucous  membrane,  catarrhal 
conditions,  germs,  stomatitis,  irregular  teeth,  malocclu- 
sion, non-occlusion  and  uncleanliness. 

Those  who  maintain  the  general  or  constitutional  eti- 
ology, ascribe  it  to  general  condition  of  health,  heredity, 
gouty  diathesis,  excessive  lime  salt  secretions,  meat  eating, 
nervous  exhaustion,  scorbutus,  environment  and  uric  acid. 
Burchard  describes  the  course  of  the  disease  as  three 
stages:  i.  Tooth  induration;  2.  erosion  by  chemical  solu- 
tion of  the  crowns  of  the  teeth;  3.  loss  of  retaining  struc- 
tures of  the  teeth. 

The  reader  should  consult  the  chart,  Fig.  15,  Chapter 
V,  for  the  relative  position  of  the  structures,  especially 
the  alveolar  sockets,  the  pericementum  and  gum  tissues. 

Regarding  the  local  causes,  when  there  is  an  excess  of 
salts  in  the  blood  and  these  are  not  eliminated,  it  is  readily 
seen  that  such  an  ideal  place  as  the  free  margins  of  the 


8o 


FIRST  AID   DENTISTRY 


gums,  becomes  a  seat  of  deposition.  Acute  inflammation 
follows  and  extends  over  the  gum  tissue  which  becomes 
turgid  and  spongy.  It  then  attacks  the  delicate  periden- 
tal membrane,  which  is  defenseless  by  reason  of  its  loca- 
tion, functions,  etc.  This  is  the  most  vulnerable  point  for 
this  process  and  for  the  development  of  bacteria,  and 
eventually  of  pus. 


^^0**^^^^^*- 

mL^ 

m¥"      r '     kPQ>  mm* 

■ 

'StBmWMMmmWMWm 

Fig.  31. — Pyorrhea   alveolaris,   left   central   incisor,   exfoliated. 


The  blood-vessels  pass  in  a  plexus  from  the  periosteum 
to  the  peridental  membrane,  and  under  normal  conditions 
remove  the  calcium  salts.  It  will  readily  be  seen,  however, 
that  under  the  perverted  condition  of  irritation  and  dis- 
turbed nutrition,  this  function  will  be  hindered  and  the 
deposition  of  salts  will  occur  instead  of  their  removal. 
Irregular  teeth,  malocclusion,  and  non-occlusion  add  to 
this  possibility  by  improper  mastication  and  interrupted 
functions  of  the  teeth,  which  should  maintain  a  healthy 


PYORRHEA   ALVEOLARIS 


8l 


condition.  Inflammation  will  result  from  mechanical  and 
chemical  causes  and  as  this  proceeds  infection  is  inevitable, 
as  the  oral  cavity  constantly  harbors  disease-producing 
organisms. 

The  specific  organisms  causing  the  infection  and  the  pus 
formation  have  not  been  isolated  and  the  various  forms 
found  have  not  been  sufficient  to  produce  the  disease  by 
inoculation  with  single  strains. 


Fig.  32. — Instruments  used  in  emergency  treatment  of  pyorrhea 
alveolaris. 


Talbot  says,  "the  pathogenic  conception  adopted  anent 
interstitial  gingivitis  is  that  the  disorder  is  a  local  inflam- 
matory condition  of  the  gums,  etc."1 

The  general  or  constitutional  causes  are  much  discussed 
and  disputed  conditions.  There  can  be  no  doubt  that 
with  a  disrupted  condition  of  health,  we  will  have  degen- 
erative conditions  of  the  various  organs  and  an  abnormal 
amount  of  salts  present  and  failure  in  proper  elimination 
increases  the  probability  of  their  effect  on  this  disease. 

1  "Interstitial  Gingivitis." 


82  FIRST  AID  DENTISTRY 

Heredity  is  claimed  to  exert  an  exceptionally  large  in- 
fluence in  some  cases. 

The  gouty  diathesis  is  the  form  which  has  been  the 
subject  of  so  much  discussion. 

However,  when  a  case  persists  and  does  not  yield  to 
local  treatment  and  the  institution  of  constitutional  treat- 
ment for  the  gout  is  accompanied  by  great  improvement 
in  the  pyorrhea  we  are  prone  to  believe  that  this  is  a  cause 
of  the  condition  under  discussion. 

The  principal  point,  which  this  brings  out  is  that  of 
improper  elimination  and  irritation  of  uric  acid,  urates 
and  calcium  salts,  in  the  deposition  next  to  the  peridental 
membrane.  Pierce  believes  this  to  be  the  local  manifes- 
tation of  the  gouty  diathesis.1 

Talbot,  however,  after  various  and  exhaustive  experi- 
mentation has  found  such  a  small  percentage  of  pyorrhea 
teeth  deposits  to  contain  uric  acid  and  urates  that  he  has 
come  to  the  conclusion  that  "uric  acid  when  it  acts  at  all, 
acts  as  a  local  irritant.  The  general  circulation,  carrying 
an  excess  of  salts  as  in  excessive  lime  salt  secretion,  de- 
posits it  through  the  process  spoken  of  above,  when  it 
becomes  a  local  irritant. 

Nervous  exhaustion  is  considered  for  the  effects  that 
follow  in  the  structure  and  the  reduction  in  tone  of  the 
immediate  organs  of  supply.  Uric  acid  is  given  as  a  result 
in  gouty  pericementitis.  Its  presence  and  irritation  is  one 
of  the  main  points,  in  the  class  considered  to  be  of  con- 
stitutional etiology. 

It  is  the  aim  of  the  writer  to  present  to  the  reader 
only  an  outline  of  the  disease,  as  it  will  be  presented  for 
diagnosis  and  enough  of  the  ideas  of  the  energetic  men 
who  have  contributed  so  much  toward  clearing  up  the 
baffling  conditions,  to  make  it  intelligently  understood. 

1  "American  Text-book  of  Operative  Dentistry." 


PYORRHEA   ALVEOLARIS 


83 


There  is  not  space  in  this  work  to  deal  otherwise  with  this 
condition. 

The  diagnosis  of  pyorrhea  alveolaris  will  be  by  sight 
and  touch.  The  gums  are  generally  red,  turgid  and  con- 
gested. Pressure  will  bring  a  show  of  pus.  Pain  in  the 
alveolar  sockets  is  not  usually  experienced.  This  point 
is  the  unfortunate  part  in  the  disease,  because  an  unob- 


Fig.  33. — Pyorrhea   alveolaris,   showing   instrument,   angle   and    fingers 
used  in  scaling  tartar. 


serving  patient  will  not  know  of  its  existence.  Hard, 
black,  brown  or  yellow  calculus  will  be  found  attached  to 
the  sides  of  the  roots  and  the  gum  tissue  will  at  times  cover 
this.  A  pus-pocket  may  exist  along  the  side  of  the  root 
unobserved,  except  that  the  tract  or  the  seepage  will  be 
noticed  at  the  gum  margins.  An  offensive  odor  attends 
the  progress  of  the  disease,  especially  in  unhygienic 
mouths.     The  diagnosis  can  be  confounded  with  a  few 


84  FIRST  AID   DENTISTRY 

other  conditions,  such  as  gingivitis,  stomatitis,  mercurial 
ptyalism,  impacted  teeth,  or  effects  of  ill-fitting  dentures. 
It  makes  its  appearance  generally  between  thirty-five 
and  fifty  years  of  age,  with  symptoms  practically  the 
same  as  acute  non-septic  pericementitis.  The  color  of  the 
gums  is  deep  red  or  purple,  over  the  ends  of  the  roots  of 
the  teeth  affected.  Constitutional  conditions  which  may 
cause  pyorrhea  and  upon  which  diagnostic  symptoms  may 
depend  will  be  gleaned  from  the  history. 

Treatment 

The  treatment  of  pyorrhea  alveolaris  in  emergency  cases 
is  to  give  relief  from  pain  and  save  teeth.  The  teeth  fre- 
quently are  very  loose  and  appear  to  have  little  attach- 
ment, but  after  the  first  treatment  and  institution  of 
prophylaxis,  they  will  tighten  to  a  surprising  amount. 
Extraction  in  chronic  cases  is  practised  where  the  absorp- 
tion of  the  peridental  membrane  and  process  has  gone 
beyond  repair,  but  in  the  first-aid  treatment  that  pro- 
cedure should  seldom  be  resorted  to.  Acute  pains  of  the 
abscess  variety  will  cause  the  patient  to  seek  relief;  and 
in  this,  temporary  treatment  will  do  a  great  deal  more  than 
might  be  supposed.  The  patient  will  present  with  severe 
pains  around  the  roots  of  the  affected  teeth.  The  gums 
will  be  purplish  and  swollen;  pressure  on  the  teeth  will 
respond  as  in  abscesses.  The  hyperaemia  and  the  pain 
of  the  gums  will  be  a  diagnostic  sign.  There  will  generally 
be  deposit  on  the  roots  under  the  gums;  and  the  teeth 
may  be  somewhat  loose.  It  is  our  duty  to  relieve  this 
patient  without  delay.  There  is  no  satisfaction  in  telling 
him  that  he  has  pyorrhea  alveolaris  and  cannot  be  cured; 
and^we  cannot  be  barbarous  enough  to  extract  the  teeth 
affected,  especially  at  this  sitting. 


PYORRHEA   ALVF.OLARTS 


85 


Wash  the  mouth  with  one  of  the  solutions  given  before 
and  use  a  syringe  to  flush  out  the  spaces  as  previously 
stated,  the  solutions  should  be  hot.  As  in  all  diseases 
the  first  rational  step  is  to  remove  the  cause. 

If  the  condition  has  a  constitutional  basis,  it  will  be 
reduced  through  systemic  channels.  The  following  treat- 
ment will  be  necessary  in  this  as  it  will  in  the  local  con- 
dition, as  the  local  effect  must  be  repaired. 


Fig.  34. — Pyorrhea  alveolaris  instrumentation. 


Fig.  32  shows  four  pyorrhea  instruments  or  files,  which 
the  writer  believes  will  be  sufficient  to  treat  emergency 
cases.  The  pyorrhea  specialist  uses  from  twelve  to  one 
hundred  instruments  for  the  treatment  of  this  condition; 
including  every  angle  and  edge  to  suit  conditions  and 
manner  of  operation  in  removal  of  tartar.     These  four 


86  FIRST  AID   DENTISTRY 

instruments  will  be  used  as  shown  in  Tigs.  33  and  34, 
to  enter  under  the  free  margins  of  the  gums  and  file  down 
or  cut  away  the  hard  deposits.  In  doing  this  care  must 
be  taken  to  follow  the  sides  of  the  teeth  and  enter  through 
the  tracts  leading  to  the  pockets. 

Remove  all  the  hard  deposits  found  and  flush  out  the 
edges  of  the  pockets  with  an  ordinary  mouth  syringe  and 
a  warm  solution.  The  gums  will  bleed  freely  and  will 
appear  to  be  very  badly  injured,  but  when  these  pockets 
have  been  scaled  and  the  gums  massaged  the  relief  given 
by  the  hemorrhage  will  be  apparent. 

The  practice  of  using  orange  wood  sticks  or  any  other 
methods  of  placing  strong  acids  in  these  sockets  in  emer- 
gency treatment  or  permanent  treatment  is  condemned. 
A  surgeon  does  not  apply  acids  to  a  fractured  joint  as  a 
treatment  under  any  circumstances,  septic  or  aseptic, 
since  necrosis  would  result.  The  same  reasoning  applies 
in  this  condition.  We  want  to  make  tissue  grow,  not 
destroy  it,  and  nature  should  be  given  an  unhampered 
opportunity.  We  should  treat  these  cases  with  the  idea 
of  getting  rid  of  the  tartar,  the  pus  and  the  excess  blood 
and  then  use  the  following  remedy  which  will  prevent  the 
germs  of  the  oral  cavity  from  entering  and  adding  to  the 
infection. 

Hartzell1  has  given  us  the  remedy  of  painting  the  gum 
margins  with  tincture  of  iodine  and  cresote  and  following 
this  with  glycerite  of  tannin,  which  will  be  seen  to  be  a 
powerful  astringent  and  anodyne,  sealing  the  edges  of 
the  gums  around  the  necks  of  the  teeth. 

Place  cotton  rolls  on  the  outside  of  the  gums  on  the 
upper  jaw,  and  on  either  side  on  the  lower.  Being  posi- 
tive that  the  pus  and  tartar  have  been  removed,  take  a 
small  pledget  of  cotton,  saturated  in  the  tincture  of  iodine 

1  "Dental  Cosmos,"  1913,   p.  1094. 


PYORRHEA   ALVEOLATE  IS  87 

and  creosote,  and  paint  around  the  gum  margins  and 
necks  of  the  teeth.  Take  another  pledget  and  sear  over 
these  with  the  glycerite  of  tannin.  This  should  be  left 
for  twenty-four  hours  and  the  patient  instructed  not  to 
brush  his  teeth.  However,  the  patient  should  be  in- 
structed to  use  the  toothbrush  the  next  day.  A  softer 
brush  than  medium,  should  never  be  used,  the  hard  bristles 
should  usually  be  advised.  Brushing  the  gums  with  soft 
brushes  does  not  give  them  the  exercise  and  friction  neces- 
sary to  reduce  them,  when  soft  and  spongy,  to  a  hard 
healthy  condition. 

The  patient  should  be  instructed  to  massage  the  gums 
with  the  finger,  which  is  a  difficult  process  in  some  parts 
of  the  mouth.  The  writer  advises  that  the  patient  hold 
a  small  amount  of  a  warm  astringent  solution  in  the 
mouth  and  with  the  cotton  rolls  shown  in  Fig.  19  on  the 
ringer,  go  all  around  the  gums.  The  patient  should  be 
instructed  to  brush  his  teeth  as  directed  in  Chapter  II. 

The  cause  being  considered  constitutional  and  the  con- 
dition in  the  mouth  as  a  local  manifestation,  the  above 
treatment  should  be  applied  and  the  patient  given  a  good 
cathartic,  advised  to  drink  a  large  quantity  of  water  and 
abstain  from  the  eating  of  foods  which  carry  much  lime 
salts. 

Constitutional  treatment  will  be  directed  by  the 
surgeon. 


CHAPTER  XII 

FRACTURES  AND  DISLOCATIONS  OF  THE  JAWS 
AND  THEIR  TREATMENT 

The  word  fracture  means  the  breaking  of  a  bone  or 
cartilage. 

Stimson  gives  the  following  classification  of  the  various 
kinds  of  fractures,  with  which  are  given  subdivisions  under 
each  head. 

i.  Incomplete  Fractures. 

2.  Complete  Fractures. 

3.  Multiple  Fractures. 

4.  Compound  Fractures. 

5.  Gunshot  Fractures. 

The  causes  of  the  fractures  of  the  bones  of  the  face  are 
many  and  varied.  The  superior  maxillary  bone  is  not 
prone  to  fracture  because  of  its  position  and  protection 
by  the  various  processes.  Fractures  of  the  bones  are 
always  produced  by  direct  violence  and  present  variance 
according  to  their  etiology.  The  various  processes  are 
fractured  with  violent  blows,  a  blow  on  the  cheek  may 
break  the  malar  bone  and  fracture  the  anterior  border  of 
the  antrum,  as  also  a  fractured  nose  may  include  the  nasal 
process.  The  alveolar  process  may  be  broken  up  exten- 
sively by  a  blow  on  the  mouth,  or  in  the  extraction  of 
teeth  such  a  blow  may  separate  the  palatal  process  from 
the  body  of  the  bone.  Stimson  quotes  a  case  of  his  prac- 
tice, in  which  the  face  was  crushed  in  an  elevator,  .... 
"  the  nasal  bones  were  separated  from  the  frontal  along  the 
suture  line,  the  right  malar  and  zygoma  broken;  and  both 
superior  maxillae  displaced  downward  and  backward  and 


FRACTURES   AND   DISLOCATIONS   OF   THE   JAWS  89 

separated  from  each  other  along  the  median  line  of  the 
hard  palate."  In  one  case  the  bones  of  the  face  were  so 
movable  that  they  moved  up  and  down  when  the  patient 
swallowed,  as  if  they  were  only  restrained  by  the  skin. 
In  order  to  produce  these  conditions,  the  extreme  violence 
necessary  and  the  extent  of  the  injury  would  seem  neces- 
sarily to  involve  the  cranium,  but  the  reason  given  for 
the  cranium's  immunity,  is  that  the  direction  of  the  force 
is  always  more  or  less  parallel  to  the  surface  of  the  cranium. 

Comminuted  (splintered  fragments  of  bone)  fractures 
often  occur  in  gunshot  wounds  and  injuries  of  all  descrip- 
tions. The  diagnosis  of  this  fracture  is  comparatively 
easy  and  can  be  made  without  difficulty  because  the  mouth 
and  external  surface  afford  easy  access  for  manipulation 
with  the  fingers.  It  presents  an  irregular  outline,  displace- 
ment, mobility  and  crepitus. 

These  cases  are  treated  by  placing  the  parts  in  proper 
relation  and  retaining  them.  The  method  advised  in  this 
chapter  is  that  of  fixation  of  the  upper  to  the  lower  jaw 
by  the  process  of  wiring  the  teeth. 

In  the  fracture  of  the  alveolar  process,  place  the  frag- 
ments of  bone  in  proper  position  and  the  teeth  in  their 
sockets  and  fix  by  wiring  or  apply  splints  made  of  gutta- 
percha over  the  cutting  edges  of  the  teeth  and  parts. 

Loose  teeth  should  be  replaced  in  the  sockets,  no  matter 
how  loose  they  appear  to  be  in  the  fracture,  as  they  will 
eventually  tighten  in  place.  Extraction  endangers  be- 
cause of  possible  removal  of  the  part  or  parts  of  bone. 

Fractures  of  the  Inferior  Maxilla 

This  fracture  is  more  common  and  important  from  the 
dental  operator's  standpoint  as  injuries  of  the  upper  lace 
will  usually  be  dealt  with  by  the  surgeon. 


90  FIRST  AID   DENTISTRY 

The  technical  knowledge  of  the  relationship  of  the  jaws 
and  the  occlusion  of  the  teeth,  together  with  the  manipu- 
lation of  these  parts  brings  the  operation  of  the  inferior 
maxilla  under  the  dentist's  care. 

Fractures  of  this  bone  generally  occur  in  patients  be- 
tween the  ages  of  twenty  and  thirty.  It  is  the  most  com- 
monly fractured  bone  of  the  face  by  reason  of  its  location 
and  function.  Its  fracture  is  much  more  common  in  men 
than  in  women. 

Incomplete  fractures  of  the  mandible  are  those  which 
only  include  the  alveolar  process  or  some  part  of  the 
border   of   the  bone.     Complete   fractures   are   those  in 
which  the  fracture  extends  through  the  entire  bone,  di- 
vided  or   classified   by   the   direction  of   the  fracture  as 
oblique,  longitudinal,  transverse,  etc.,  and  comminuted. 
Compound  fractures  are  those  in  which  the  membrane 
covering  the  bone  is  broken  or  cut.     They  present  an  open 
wound. 
Gunshot  fractures  are  as  the  name  implies. 
In  the  extraction  of  teeth,  in  blows,  falls  or  any  external 
violence  against  the  teeth  or  face,  the  alveolar  process  is 
very  liable  to  be  broken,  as  is  also  a  part  of  the  border. 

The  writer  has  recently  had  a  case  of  fracture  of  the 
mandible,  in  which  the  external  plate  of  the  alveolar  pro- 
cess was  fractured  from  the  right  to  the  left  cuspid  tooth 
with  a  small  triangular  fragment  broken  from  the  body 
of  the  bone.  His  history  showed  fracture  seven  years 
before.  There  had  been  continual  drain  from  the  lower 
central  incisors,  which  moreover  were  affected  with  pyor- 
rhea alveolaris.  The  displaced  alveolar  plate  became 
firm,  but  the  fragment  of  the  body  of  the  bone  was  re- 
moved because  of  necrosis,  Figs.  37  and  38,  and  the  two 
central  incisorsjwere  later  extracted. 

Complete  fractures  occur  more  frequently  in  the  anterior 


FRACTURES    AND   DISLOCATIONS    OF   THE    JAWS  01 

portion  of  the  bone.  Stimson  states  that  "of  75  single 
ones  of  these,  the  fractures  occupied  the  median  line  in  25, 
the  region  of  the  anterior  in  22,  that  of  the  back  teeth  in  15, 
behind  the  teeth  in  8  and  in  the  condyloid  process  in  5." 

In  the  writer's  experience  the  majority  of  cases  have 
been  multiple  fractures,  mostly  double.  This  condition 
has  been  obtained  probably  by  reason  of  the  difficulties  in 
these  cases,  the  necessity  of  dental  technic,  affording  the 
opportunity  in  consultation.  The  fracture  of  the  body 
of  the  bone  generally  has  a  vertical  direction;  in  the  ramus. 
it  is  usually  oblique. 

The  fractures  through  the  symphysis  or  the  vicinity  of 
the  anterior  teeth  do  not  show  great  displacement,  part 
of  the  lines  of  occlusion  of  the  teeth  being  correct,  however, 
a  slight  separation  of  the  teeth  in  the  respective  fragments 
will  generally  be  noted.  Posterior  to  the  cuspid  teeth, 
the  fracture  will  be  more  easily  noted,  the  abnormal  occlu- 
sion being  prominent  because  of  the  action  of  the  masseter 
and  pterygoid  muscles. 

In  a  case  in  the  writer's  practice  a  simple  fracture 
through  the  symphysis  was  not  noticed  for  three  weeks 
after  the  accident,  when  inability  to  masticate  brought  the 
patient  for  treatment.  In  shooting  a  rifle,  the  rebound 
caused  the  stock  to  come  forcibly  in  contact  with  the 
point  of  the  chin  and  a  vertical  fracture  resulted. 

Another  case  of  compound  fracture  presented.  A  pa- 
tient while  under  the  influence  of  alcohol  was  struck  on 
the  point  of  the  chin,  from  the  right  side  and  neglected 
treatment  for  several  days.  Examination  showed  a  frac- 
ture through  the  body  of  the  bone  at  the  left  of  the  lower 
left  lateral  incisor,  one  through  the  socket  of  the  right 
cuspid  and  one  anterior  to  the  second  molar,  the  first 
molar  being  absent.  The  mouth  was  foul  and  infected, 
the  patient  at  the  time  had  various  venereal  diseases.     The 


92  FIRST  AID  DENTISTRY 

anterior  fragment  was  drawn  directly  back  into  the  mouth, 
the  teeth  pointing  almost  toward  the  tongue,  the  other 
fragment  was  drawn  in  also,  the  anterior  part  overlapping 
the  former,  the  posterior  portion  was  in  good  position. 

In  another  case,  the  patient  received  a  blow  on  the  point 
of  the  chin  with  a  stool,  with  fracture  through  the  sym- 
physis, and  between  the  second  bicuspid  and  first  molar. 
Patient  had  failed  to  report  and  infection  followed,  the 
jaw  had  been  lanced  on  the  outer  surface  and  drained. 
The  parts  were  not  in  very  bad  alignment  and  were  pain- 
ful only  upon  movement.  A  large  amount  of  necrosis  fol- 
lowed in  this  case,  with  resultant  removal  of  sequestra. 

Many  cases  of  abscess  opening  into  the  mouth  are 
associated  with  small  fragments  of  bone,  these  are  exfolia- 
tions or  splinters  and  must  be  removed.  The  diagnosis  of 
fractures  of  the  inferior  maxilla  is  comparatively  simple, 
as  the  observation  of  the  parts  and  manipulations  will  show 
abnormal  mobility,  crepitus,  displacement  and  pain. 

Treatment 

There  are  many  and  varied  means  of  treating  these 
cases;  and  as  is  true  of  all  conditions,  many  which  answer, 
but  are  not  sufficient.  The  treatment  of  the  mouth  should 
be  taken  first  and  the  hot  solution  of  one  of  the  mouth 
washes  used  to  flush  it  out.  The  use  of  a  swab  of  cotton 
to  go  gently  over  all  the  teeth  and  get  the  field  as  clean  as 
possible  makes  the  patient  grateful,  the  working  in  the 
cavity  more  pleasant  and  safer.  The  class  and  extent  of 
the  fracture  should  be  determined  and  the  method  of 
retaining  selected. 

In  edentulous  jaws,  where  there  is  no  occlusion  of  the 
teeth  to  determine  the  proper  placing  of  the  parts;  the  use 
of  the  four-tailed  bandage  and  gutta-percha  splints  will  be 
found  the  best  method  of  retention. 


FRACTURES   AND    DISLOCATIONS   OF   THE    JAWS 


93 


A  wax  mold  should  be  made  of  the  upper  and  lower  jaw 
and  a  wax  bite  secured,  plaster  casts  made  and  mounted 
on  an  articulator,  over  which  warm  gutta-percha  should 
be  molded,  cooled  and  trimmed  to  At  the  case.  Insert  in 
position  and  apply  the  bandage  using  a  pad  covered  by 


Fig.  35. — Bandaging  the  jaws  together  (modified-Barton's).     Front  view. 


a  piece  of  wet  cardboard  under  the  chin,  Figs.  35  and 
36. 

The  method  of  wiring  the  teeth,  in  the  author's  opinion, 
presents  the  quickest  and  easiest  as  well  as  the  most 
sanitary  and  surest  method  of  proper  retention.  The 
parts  of  the  fracture  are  brought  directly  before  the  eye 


94 


FIRST  AID   DENTISTRY 


of  the  operator,  during  the  entire  operation  and  treatment. 
In  complicated  cases,  it  serves  the  purpose  far  better  than 
splints,  because  of  ability  to  reduce  gradually  or  separate 
the   jaws  without   disturbing    the   union.     There  is  no 


Fig.  .36. — Rear  view  of  Fig.  35. 


method  whereby  control  from  mobility  can  be  secured  as 
with  the  wiring  process. 

In  the  first  case  cited  an  X-ray  plate  was  made,  Fig. 
37,  which  showed  there  was  not  a  complete  fracture,  the 
lower  teeth  were  tied  together  in  the  sockets  and  an  align- 
ment wire  placed  over  the  entire  lower  set,  by  inter-lacing 
with  twenty  gauge  wire.     The  jaws  were  fastened  together 


FRACTURES    AND    DISLOCATIONS    OF   THE    JAWS         95 

for  ten  days.  The  wound  was  dressed  and  packed  with 
gauze,  dipped  in  iodoform,  orthoform  and  campho-phe- 
nique  paste.  The  case  was  painful  and  the  drain  of  the 
pus  persisted.  Removal  of  the  two  central  incisors  and 
incision  was  made  over  the  fragment  of  bone  which  was 
removed  and  the  case  was  practically  cured,  Fig.  38. 

Robert  T.   Oliver1  has  given   a   method  of  wiring  a 
slightly  transverse  fracture  through  the  socket  distally 


Fig.  37.- — Fracture.  Case 
1 — Maxillary  process,  in- 
volving border  of  body  of 
maxillary  bone.  Radio- 
graph.— {A  ulhor's  practice.) 


Fig.  38. — Case  1,  one  month  after 
removal  of  sequestra  and  teeth,  process 
firmly  re-attached.  Radiograph. — 
(A  itthor's  practice.) 


of  the  first  bicuspid  and  mental  foramen.  He  uses  copper 
wire,  annealed,  about  4  inches  long,  inserts  one  end  through 
the  space  between  the  lateral  and  canine  teeth,  burnishes 
lingually  to  the  canine,  pulls  through  half  the  length, 
brings  it  back  through  between  the  canine  and  bicuspid, 
then  the  other  end  is  inserted  between  the  canine  and  bi- 
cuspid, burnished  to  the  lingual  side  of  the  first  and  second 
bicuspids,  carried  back  across  the  fracture,  inserted  from 
1  "Dental  Cosmos,"  Sept.,  191 1. 


96 


FIRST  AID   DENTISTRY 


Fig.  39. — Dr.  O.  T.  Oliver's  method  of  wiring  across  the  fracture.     Pencil 
mark  representing  fracture. 


Fig.  40.— Method  of  lacing  teeth  and  wiring  across  the  fracture,  wires 
loosely  applied  for  photographic  clearness.  .  . 


FRACTURES  AND   DISLOCATIONS   OF   THE    JAWS 


97 


within  through  the  space  between  the  first,  molar  and  sec- 
ond bicuspid,  brought  forward  taut  and  the  ends  twisted, 

Fig.  39- 

Fig.  40  shows  the  author's  method  of  reducing  by  lacing 
the  teeth  with  a  wire  about  6  inches  long  and  bringing 
the  cross  forward  between  each  tooth  except  the  two 
adjoining  teeth  on  cither  side  of  the  fracture,  where  the 
wire  extends  along  each  side  of  the  two  approximating 


Fig.  41. — Wires  in  place  on  the  teeth  previous  to  reduction  and  twisting. 


teeth,  then  to  cross  again,  the  cuspid  encircled  and  the 
ends  of  the  wires  twisted  at  the  cuspid  tooth. 

This  process  is  used  in  fractured  bones  to  draw  together 
and  retain  the  parts.  The  teeth  of  the  full  upper  jaw  are 
wired  as  follows:  Small  wires  about  2  inches  long  are 
placed  tightly  around  the  gingival  margins  under  the  gums 
and  twisted  in  the  same  direction,  preferably  to  the  right, 
on  each  tooth.     The  number  of  the  teeth  wired  in  this 


98 


FIRST  AID   DENTISTRY 


manner  will  be  determined  by  the  amount  of  fixation 
deemed  necessary.  The  lower  teeth  opposite  the  uppers 
are  all  wired  to  correspond  with  the  other  and  the  wires 
turned  forward  in  the  mouth,  Fig.  41. 

The  reducing  wire  is  twisted  until  the  parts  appear  to 
be  together  in  contact  and  then  the  jaws  are  closed  and 
held  by  an  assistant.     Then  on  the  side  which  is  not  frac- 


Fig.  42.- 


-Wires  twisted  showing  free  end,  before  bending  into  spaces 
between  teeth. 


tured,  twist  the  wires  of  opposing  teeth  until  the  cusps 
are  almost  in  proper  contact.  Fig.  42 ;  the  fractured  side 
is  then  drawn  up  in  the  same  manner  as  near  as  possible. 
If  the  parts  are  swollen  or  too  painful  absolute  contact 
will  be  difficult  and  in  this  method  it  is  unnecessary, 
since  the  parts  can  be  moved  or  reduced  gradually  for 
seven  days. 

Place  a  bandage  over  the  head  as  shown  in  Fig.  35, 
to  counteract  the  muscular  contraction  which  tends  to 


FRACTURES   AND   DISLOCATIONS    OF   THE    JAWS 


99 


break  the  wires.  A  gauze  pack  covered  by  a  piece  of  wet 
cardboard  is  molded  over  the  skin  and  this  is  covered  by 
the  bandage,  which  need  only  be  worn  for  a  few  days. 

Traction  on  these  fragments  is  nearly  always  desired 
and  the  wiring  process  presents  full  possibilities  for  the 
action  required.     This  is  the  great  advantage  over  all 


Fig.  42a. — Twisted  ends  of   wires  turned   in   and  covered   with   gutta- 
percha to  protect  the  lips. 


other  methods.  Dr.  Oliver1  describes  an  original  method 
of  constructing  an  anchor  loop  for  the  alignment  wire, 
of  either  upper  or  lowers,  by  twisting  a  copper  wire  around 
a  mandrel  thus  making  a  loop,  which  can  be  tacked  with 
hard  solder  and  placed  at  the  point  desired  for  application 
of  the  traction  wire. 

There  is  no  necessity  for  extracting  any  teeth  in  this 
nut  hod  for   feeding  purposes  as  the  patient  under  any 

1  "Dental  Cosmos,"  191 1. 


IOO  FIRST   AID   DENTISTRY 

circumstances  is  required  to  subsist  on  liquid  diet  and 
the  entrance  of  this  has  sufficient  space  around  the  pos- 
terior teeth.  The  patient  may  also  be  fed  by  a  tube  passed 
through  the  nostril. 

The  wires  are  cut  short  and  covered  with  wax  or  gutta- 
percha, which  is  changed  daily.  Fig.  42a.  They  are 
brushed  with  a  small  brush,  syringed  out  and  a  good 
mouth  wash  advised.  Hydrogen  peroxide  is  valuable  in 
the  wash  for  cleaning  around  the  wires. 

In  cases  where  union  is  delayed,  with  the  lower  jaw 
wired  to  the  upper  and  the  alignment  wires  in  place,  it 
is  a  simple  matter  to  loosen  the  jaws  by  untwisting  the 
wires;  if  it  is  necessary  to  incise  and  scrape  the  edges  of 
the  fracture  or  remove  sequestra  or  splinters.  Where  the 
union  of  the  fragments  demands  that  the  wire  be  placed 
through  the  bone,  the  process  is  simple  Make  an  incision, 
through  the  soft  tissue  in  a  line  along  the  body  of  the  bone, 
separate  the  soft  parts  from  the  bone  then  with  a  spear 
point  or  cone-shaped  drill,  make  a  hole  through  the  proc- 
ess between  the  teeth  on  either  side  of  the  fracture,  being 
careful  to  have  plenty  of  structure  between  the  edges  of  the 
fracture  and  the  hole.  Place  a  twenty  gauge  silver  wire 
through  the  hole,  with  the  free  ends  on  the  outside,  twist 
until  apposition  is  secured.  Leave  this  twisted  part  of 
the  wire  about  an  inch  long  and  if  necessary  stitch  the 
wound  on  either  side,  leaving  the  twisted  ends  of  the  wire 
exposed.  When  the  union  is  accomplished,  clip  the  pos- 
terior portion  of  the  wire  beneath  the  twisted  part  and 
carefully  remove  it  by  holding  the  twisted  portion  in  a 
pair  of  pliers  and  pulling  forward  along  the  line  of  the 
bone. 

Cases  should  heal  in  from  three  to  six  weeks  and  with- 
out deformity  or  improper  occlusion,  such  as  often  results 
where  the  teeth  are  hidden  from  view  by  the  use  of  splints. 


fractures  and  dislocations  of  tdk  jaws      ioi 

Dislocation  of  Lower  Jaw 

There  is  nothing  so  distressing  to  the  patient  as  a  dis- 
location of  the  lower  jaw.  A  study  of  the  anatomy  of  the 
part  will  show  the  comparative  ease  with  which  the  dis- 
location occurs.     It  occurs  in  from  3  to  6  per  cent,  of  all 


Articular 
eminence 
Synovial 
membrane 
Glenoid  fossa 


Condyle  of 

inferior 

maxilla 


Fig.  43. — Temporo  maxillary  articulation. 

dislocations.     Fig.  43  shows  the  joint  in  proper  relation- 
ship with  the  parts  noted. 

The  glenoid  fossa  is  the  socket  which,  lined  with  a  pad, 
the  synovial  membrane,  receives  the  condyle  of  the  in- 


102  FIRST   AID   DENTISTRY 

ferior  maxilla.  The  articular  eminence  forms  the  anterior 
border  of  the  fossa.  In  dislocations,  the  condyle  comes 
forward  over  this  eminence. 

Backward  and  internal  or  external  dislocations  are  rare, 
without  other  complications.     The  condyle  is  attached  by 


Fig.  44. — Method  of  reducing  dislocated  maxilla   with  use  of  pencil 
between  the  teeth. 

ligaments,  the  capsular,  internal  and  external  lateral, 
which  are  stretched  during  the  dislocation. 

Relaxation  of  these  ligaments  and  contraction  of  the 
muscles,  violence  in  the  mouth,  laughing,  shouting,  yawn- 
ing, vomiting  and  dental  extractions,  are  the  most  com- 
mon causes  of  dislocation,  one  or  both  sides  may  be 
dislocated. 

The  symptoms  of  the  condition  include  a  protrusion  of 


FRACTURES   AND    DISLOCATIONS    OF   THE    JAWS        IO3 

the  lower  teeth,  a  depression  in  front  of  the  car  and  ina- 
bility of  the  patient  to  manipulate  the  jaw.  If  unilateral 
the  chin  will  point  to  the  opposite  side. 

The  treatment  is  the  reduction  of  the  condition  which 
ordinarily  in  recent  cases  is  not  difficult. 

Fig.  44  illustrates  one  method  of  reduction,  after  placing 
a  pencil,  a  small  stick  or  cork  between  the  molar  teeth, 
the  operator  standing  at  the  patient's  back,  by  upward 
pressure  on  the  chin  forces  the  condyle  down  to  a  level 
with  the  articular  eminence,  a  slight  pull  aided  by  the 
action  of  the  muscles,  will  then  be  sufficient  to  snap  the 
jaw  into  place. 

The  thumbs  of  the  operator  may  be  bandaged  and  placed 
in  the  mouth,  operator  in  front  of  patient  and  pressure 
made  on  the  molar  teeth  with  an  upward  force  applied 
under  the  chin  and  relocation  gained  in  this  manner. 

The  use  of  the  jaw  should  be  limited  for  a  few  days;  in 
severe  cases  a  bandage,  as  shown  above,  applied  for  such 
time  as  the  operator  deems  necessary. 


CHAPTER  XIII 
DENTAL  EXTRACTIONS 

Throughout  this  book,  appeal  has  been  made  to  save 
the  teeth.  When  extraction  has  been  decided  upon  it 
will  be  assumed  that  all  the  resources  of  treatment  have 
been  exhausted  Many  writers  have  made  various  rules 
for  dentists  to  follow  in  deciding  to  extract,  but  with  all 
respect  to  them,  the  judgment  of  the  operator  in  each  case 
must  decide. 

It  is  impossible  to  pull  certain  teeth,  which  with  proper 
manipulation  will  yield  with  comparative  ease.  The  pro- 
cedure described  by  the  expression  that  "the  patient  was 
dragged  all  over  the  office  or  that  the  operator  pulled 
with  all  his  strength,  etc.,"  is  barbarous  and  absolutely 
unnecessary.  The  erroneous  idea  given  by  the  words 
"pulling  or  drawing  teeth"  will  be  eliminated  and  replaced 
by  the  proper  words  "extracting  or  removing  teeth." 

The  nervous  condition  of  the  patient  tends  to  influence 
the  operator  to  hurry  and  there  is  no  operation  which 
demands  deliberate  and  concise  actions  as  does  extracting. 

Improper  methods  and  ill-applied  force  cause  so  many 
accidents  in  extraction  of  teeth  that  exact  knowledge  of 
the  structures  and  their  relations  is  necessary.  The  acci- 
dents include  fracturing  the  jaw  or  alveolar  process,  re- 
moving parts  of  the  floor  of  the  maxillary  sinus,  fracturing 
of  other  teeth,  extraction  of  the  wrong  or  more  than  one 
tooth  and  in  injuries  to  the  tongue  and  soft  tissues.  The 
points  given  under  the  extraction  of  each  tooth,  will  aid 
in  rational  extraction. 

104 


DENTAL  EXTRACTIONS  105 

Failures,  accidents  and  complications  occur  in  extrac- 
tions and  these  must  be  guarded  against  by  a  study  of  the 
parts,  knowledge  of  the  eruption  of  teeth,  care  and  proper 
manipulation  of  instruments  and  consideration  of  oral 
sepsis,  during  and  after  operation. 

Failures  in  removing  all  of  the  root  or  roots  of  teeth 
occur  for  various  reasons.  Some  teeth  present  a  ball  at 
the  end  of  the  root.  This  will  give  great  difficulty  and 
probably  be  left  in  the  jaw,  the  root  breaking  above  the 
ball.  Other  roots  may  break  in  the  socket;  and  while  the 
practice  is  not  correct,  operators,  who  are  not  thoroughly 
experienced  will  do  well  to  restrain  from  too  strenuous 
efforts  to  get  these  roots. 

In  the  extraction  of  the  upper  molars  and  bicuspids  the 
roots  impinge  closely  upon  and  sometimes  enter  the  cavity 
of  the  maxillary  sinus.  Faulty  or  forceful  extraction  is 
liable  to  bring  out  a  large  portion  of  the  bone  which  forms 
the  floor  of  this  cavity,  and  serious  complications  result. 

The  extraction  of  the  deciduous  teeth  or  roots  must  be 
accompanied  with  caution,  as  to  the  distance  the  forcep 
beak  is  forced  under  the  process  since  there  is  liability  of 
injury  to  permanent  teeth,  which  he  underneath. 

In  grasping  a  tooth  through  the  alveolar  process,  in 
cases  of  roots  deeply  imbedded  in  the  tissue,  to  force  it 
from  the  socket  by  pressure  on  either  side  of  the  alveolar 
plate,  application  of  too  much  force  is  liable  to  carry  away 
a  large  quantity  of  the  process.  The  reverse  of  this,  the 
introduction  of  the  beaks  of  the  forceps,  which  are  too 
thick,  between  the  root  and  process  is  liable  to  sever  or 
spread  the  process  to  the  extent  of  fracture. 

The  opposite  teeth  are  easily  fractured  by  slipping  for- 
ceps and  a  guard  should  be  made  by  a  linger  of  the  oppo- 
site hand.  There  is  danger  of  the  tooth  falling  into  the 
throat,  after  removal  from  the  socket,  in  withdrawing  it 


io6 


FIRST   AID  DENTISTRY 


from  the  mouth,  especially  is  this  true  of  the  wisdom 
teeth,  if  extracted  with  forceps  which  have  too  large  a 
bow  in  the  beaks. 

The  patient  should  always  be  placed  in  such  a  position 
that  the  operator  may  have  full  view  of  the  tooth,  or  that 


Fig.  45. — Lancing  gums  over  erupting  third  molar,  showing  triangular 
incision,  outer  surface. 

the  lingers  of  the  left  hand  may  guard  the  beaks  from  the 
danger  of  including  another  tooth. 

Precaution  from  infection  during  the  operation  should 
be  taken.  Large  exposed  wounds  or  sockets  should  be 
kept  clean  with  a  hot  solution  of  one  of  the  antiseptic 
mouth  washes  previously  mentioned,  until  granulation 
begins  and  the  socket  closes.  The  treatment  of  infected 
sockets  will  be  taken  up  later. 


DENTAL    EXTRACTIONS 


IO7 


The  practice  of  lancing  the  gums,  in  extraction  of  teeth 
with  crowns  and  a  free  gum  margin,  is  not  always  advised; 
but  with  roots,  it  is  seldom  that  the  slitting  of  the  gum  is 
not  necessary. 

To  lance  this  tissue  use  a  sharp,  straight  or  curved 
la  met ;  and  free  the  tissue  from  the  root  on  either  side  for 
the  reception  of  the  beaks  of  the  forceps,  or  make  a  short 


Fig.  46. — Lancing  gums  over  erupting  third  molar,  showing  triangular 
incision,  inner  surface. 


incision  on  the  inner  and  outer  gum  surface  parallel  to 
the  root  and  through  to  the  bony  process. 

In  the  lower  wisdom  teeth,  if  extraction  is  contemplatut, 
or  eruption  to  be  aided,  cross  lancing  is  not  advised,  bed 
a  triangular  piece  of  the  gum  should  be  removed.  Make 
an  incision  from  a  high  posterior  point  over  the  tooth  to- 
ward the  outer  surface.  Fig.  45  and  then  one  on  the  inner 
as  shown  in  Fig.  46  and  then  by  a  cross  incision,  remove 


io8 


FIRST  AID   DENTISTRY 


the  gum  tissue  thus  severed.  If  this  tooth  is  to  be  ex- 
tracted it  will  be  a  simple  matter  to  grasp  the  tooth  with 
the  forceps. 

In  preparing  to  extract  a  tooth,  take  the  mouth  mirror 
and  with  an  explorer  go  all  around  the  tooth  and  notice 
its  attachment,  its  roots,  and  the  angle  as  which  it  sets  in 


Fig.  47. — Elevators  to  be  used  in  the  extraction  of  roots. 

the  process.  The  writer  then  paints  the  tooth  and  sur- 
rounding tissue  with  tincture  of  iodine.  Many  times  in- 
fection which  lies  in  and  around  the  tooth  is  carried  down 
into  the  sockets.  This  procedure  seems  to  prevent  this, 
the  iodine  exerting  the  antiseptic  action. 

The  choice  of  the  forceps  should  be  made  with  considera- 


DENTAL  EXTRACTIONS  IO9 

tion  of  four  points,  viz.,  1.  The  shape  and  the  size  of  the 
beak  should  fit  the  tooth  or  root  and  not  obstruct  the 
view  of  the  tooth.  2.  The  handles  should  fit  the  hand  of 
the  operator  when  the  beaks  are  separated  to  the  point 
necessary  to  grasp  the  tooth  and  the  handles  should  be 
serrated  to  aid  the  grip  so  that  the  sensitiveness  of  the 
hand  to  resistance  in  extraction  will  not  be  destroyed.  3. 
They  should  be  of  proper  material  (good  steel)  and  not 
bend  or  break  under  stress.  4.  They  should  be  cleaned 
and  sterilized  before  using. 

The  large  number  of  forceps  on  the  market  represents 
many  particular  kinds  devised  by  individuals  and  some 
of  these  cannot  be  used  by  most  operators.  Doubt  is 
felt  as  to  whether  they  can  be  used  with  success  by  the 
men  who  devised  them. 

The  extraction  of  teeth  by  elevators  is  at  times  very 
satisfactory,  it  is  a  simple  matter  to  place  the  beak  down 
into  the  socket  and  by  a  prying  movement  force  the  root 
from  the  socket.  The  extraction  of  each  individual  tooth 
and  its  root  will  be  taken  up,  in  detail. 

The  Procedure  of  Extracting 

The  knack  or  art  of  extracting  does  not  depend  upon 
the  strength  of  the  operator,  but  lies  in  the  sensitiveness 
of  the  hand  to  the  giving  away  of  attachment  and  the 
resistance  of  the  tooth.  This  should  guide  the  operator  in 
applying  force  of  withdrawal,  as  the  teeth  should  be 
loosened  before  removal  is  begun. 

The  writer  places  the  patient  as  low  as  possible  in  the 
dental  chair  and  attempts  to  keep  the  head  as  near  a 
line  of  his  waist  as  possible.  This  will  keep  the  elbow 
down  and  afford  a  sort  of  fulcrum.  If  the  elbow  is  above 
the  line  of  control  of  the  shoulder  muscles,  difficulty  will 


no 


FIRST  AID   DENTISTRY 


generally  be  experienced.  The  patient  is  tipped  back  for 
aUpf  the  upper  teeth  and  sits  upright  for  all  of  the  lower. 
The  protection  of  the  lips  must  be  made  by  the  fingers  of 
the  left  hand. 


Fig.  48. — Position  of  hand  and  thumb  gripping  forceps  for  upper  anterior 
teeth  and  roots. 

Extraction  or  the  Upper  Teeth 
Examine  all  teeth  surrounding  with  a  mirror. 

Central  Incisors 

One  large,  strong,  round,  conical  root;  select  forceps 
shown  in  Fig.  48,  or  similar  pair. 

Take  position  as  shown  in  Figs.  50  or  51. 


DENTAL   EXTRACTIONS 


III 


Place  inner  beak  of  forceps  well  up  on  lingual  surface  at 
edge  of  enamel,  gently  close  the  forceps  over  the. outer  sur- 
face and  with  a  rotary  movement,  force  the  beaks  under 
the  gums  until  they  touch  the  alveolar  process  Fig.  52. 

Rotate  and  twist;  using  an  "in-and-out  "motion  if  resist- 
ance so  demands;  when  loosened  withdraw  straight  from 


Fig.  49. — Position   of   hand   gripping  forceps,   thumb   placed   between 
handles  to  prevent  crushing  tooth. 

the  socket.     Press  alveolar  walls  together  with  the  thumb 
and  finger. 

The  extraction  of  the  root  of  this  tooth  is  practically  the 
same  procedure,  except  where  it  is  broken  off  far  under 
the  process  and  it  cannot  be  gripped  with  the  forceps, 
then  after  lancing  the  gums  parallel  to  the  root,  place  the 


112 


FIRST   AID  DENTISTRY 


beaks  of  a  root  forceps  as  shown  in  Fig.  53  and  pressure 
will  generally  spring  the  tooth  from  the  socket. 

The  Lateral  Incisor 

One  small,  flattened  root,  curved  somewhat  toward  the 
canine. 

Use  same  forceps  as  for  central. 


Fig.  50. — Position   for  operator.     Extraction  of  teeth — upper  left  side 

of  jaw. 

Take  the  same  position. 

Apply  the  forceps  the  same  as  with  the  central. 

Place  forceps  on  the  tooth  in  the  same  manner. 

Use  an  "in-and-out  motion"  and  if  resistance  is  felt, 


DENTAL   EXTRACTIONS 


"3 


Fig.  51. — Position  of  operator.     Extraction  of   teeth — upper  right  side 

of  jaw. 


Fig.  52. — Extraction  of  upper  incisor  teeth. 


ii4 


FIRST   AID   DENTISTRY 


use  a  rotary  movement.  Any  movement  may  be  used 
which  the  operator  feels,  in  his  hand,  is  breaking  the 
attachment. 

Withdraw  the  tooth,  when  loosened,  directly  from  the 
socket.     Press  alveolar  walls,  with  the  thumb  and  finger. 


Fig.  53. — The  extraction  of    the    upper    anterior    roots.     Forceps    in 
position  to  compress  or  cut  through  the  alveolar  process. 

The  extraction  of  the  lateral  root  is  practically  the  same 
as  that  of  the  central  incisor. 


The  Cuspid  or  Canine 
{Called  the  Eye  Tooth) 

One  long,  slightly  flattened  round  root. 

Sets  in  the  jaw  more  firmly  than  any  other  tooth.  Last 
to  erupt,  therefore  frequently  malposed  and  the  root 
wedged  between  the  lateral  and  bicuspid. 


DENTAL  EXTRACTIONS 


115 


Roots  project  at  times  into  the  maxillary  sinus. 

Use  forceps  shown  in  Fig.  48  or  one  with  a  straight 
beak. 

Apply  forceps  on  the  tooth  in  the  same  manner  a 
shown  in  Fig.  54. 

This  tooth  is  at  times  twisted  and  pressure  on  the  for- 
ceps should   be  applied  "in  and  out,"  in  a  line  of  its 


Fig.  54. — Forceps  in  position.     Extraction  upper  cuspid. 

greatest  thickness,  a  rotating  movement  will  be  used  to 
advantage  and  sometimes  a  backward  motion.  The  sen- 
sitiveness of  the  hand  will  show  the  line  of  least  resist- 
ance .  When  loosened  it  is  usually  easily  removed.  Press 
alveolar  walls  together  with  thumb  and  linger. 

The  extraction  of  the  root  is  practically  the  same  as 
the  tooth,  except  where  it  is  broken  under  the  process. 
In  this  case,  lance  the  gum  to  the  bone  on  the  labial  side, 
observe  the  direction  of  the  root,  and  if  wedged  remove  a 
small  portion  of  the  process  with   elevator  No.    1,   Fig. 


1 1 6  FIRST  AID  DENTISTRY 

47,  place  beak  of  forceps  well  up  on  the  inner  side  and 
remove  straight  out  from  the  labial  process. 

First  and  Second  Bicuspids 

The  first  bicuspid:  Usually  two  small,  divergent  roots 
which  are  generally  round. 

Use  forceps  shown  in  Fig.  55,  and  apply  in  same  man- 
ner as  incisors. 

Take  position  as  shown  in  Fig.  50  or  51. 


Fig.  55. — Extraction  of  upper  left  bicuspids,  showing  guard  of  finger 
behind  forceps. 

Use  an  "in-and-out"  motion.  The  tooth  will  loosen 
in  many  cases  but  not  be  easily  removed  because  of  the 
bony  process  within  the  bifurcation.  Carrying  the  tooth 
outward  will  generally  bring  the  tooth  away,  the  outer 
alveolar  process  being  thinner  than  the  inner.  In  case 
difficulty  occurs,  these  roots  can  be  separated  and  removed 
with  the  root  forceps,  shown  in  Fig.  53. 


DENTAL  EXTRACTIONS  117 

The  second  bicuspid  has  a  single  slightly  flattened  root. 
Occasionally  there  are  two. 

The  application  of  the  forceps  and  extraction  is  prac- 
tically the  same  as  the  first  bicuspid. 

The  roots  of  these  teeth  will  be  removed  with  the  forceps 
shown  in  Fig.  53.  If  one  root  of  a  double-rooted  tooth 
remains,  place  one  beak  of  the  forceps  in  the  socket  and 
the  other  under  the  gums,  and  process.  Its  extraction 
will  be  simple. 

The  First  and  Second  Molars 

These  upper  molars  are  very  similar  and  the  procedure 
in  one  the  same  as  in  the  other,  they  both  have  three  roots, 
one  palatal  (inside)  and  two  buccal  (outside).  Consult 
Fig.  14.  They  vary  in  degrees  of  separation  and  there 
is  no  set  rule  for  their  extraction. 

These  teeth  are  the  most  commonly  broken  by  inex- 
perienced operators,  by  cutting  the  crowns  with  too  much 
pressure  on  the  forceps.  Forceps  Fig.  56  has  grooves 
divided  by  a  point  on  the  outer  beak,  which  fits  between 
the  buccal  roots.  A  right  and  left  pair  of  this  forceps 
must  be  used. 

Apply  forceps  well  down  under  the  gums,  and  with  the 
thumb  pressed  between  the  handles  to  prevent  too  great  a 
pressure  on  the  beaks,  force  with  an  inward  motion.  This 
places  the  inner  beak  well  up  on  the  single  root  and  then 
force  outward  gripping  tightly.  When  the  beak  is  felt  to 
go  between  the  roots,  proceed  with  a  slow,  steady,  inward 
movement,  the  outer  roots  will  give.  The  inner  root  will 
follow  generally  in  the  reverse  outward  motion. 

Rocking  the  tooth  will  loosen  the  attachment.  Rota- 
tion is  impossible. 

Withdraw  outward. 


n8 


FIRST   AID   DENTISTRY 


The  roots  of  these  teeth  to  be  removed  when  the  crown 
is  missing  should  be  taken  one  at  a  time.  Use  root  for- 
ceps shown  in  Fig.  53.  Take  the  anterior  root  first,  with 
a  direct  in-and-out  motion.  The  other  buccal  root,  with 
rotary  motion,  and  lastly  the  palatal  root,  the  outer  beak 
being  placed  in  one  of  the  empty  sockets,  apply  pressure 
upward  and  then  remove  in  the  line  of  the  direction  of 
the  root,  outward  and  downward. 


Fig.  56. — Extraction  of  upper  left  molars. 

The  Third  Molar 
(Wisdom  Toolh) 

The  number  of  roots  varies  from  one  to  seven.  The 
majority  have  one^and  three.  The  upper  third  molar  is 
the  easiest  tootlTextracted. 

The  bayonet-shaped  forceps,  Fig.  48,  in  the  writer's  ex- 


DENTAL   EXTRACTIONS 


ri9 


perience  is  the  best  shape  to  be  used,  although  the  forceps 
shown  in  Fig.  57  is  larger  and  heavier  and  in  inexperi- 
enced hands  may  prove  more  satisfactory.  Take  position 
as  with  other  teeth  on  the  proper  side,  Fig.  50  or  Fig.  5 1 . 
Place  outer  beak  over  the  buccal  surface  of  the  tooth 
and  bring  inner  beak  to  place,  force  the  forceps  up  in  the 
line  which  it  now  stands.     Grip  the  tooth  and  turn  upward 


Fig.  57. — Extraction  of  upper  left  third  molar  wisdom  tooth,  showing 
fingers  guarding  against  dropping  the  tooth  down  the  patient's  throat. 


and  outward;  an  inward  motion  does  no  good  until  the 
tooth  is  loosened  in  the  socket. 

The  fingers  may  be  placed  inside  the  mouth  as  shown 
in  Fig.  57,  just  before  removal  to  prevent  the  tooth  from 
slipping  through  the  forceps  into  the  throat. 

The  inner  alveolar  plate  is  very  thick  and  the  outer  one 

thin,  so  the  in-and-out  motion  is  not  used. 
9 


120 


FIRST  AID  DENTISTRY 


The  Lower  Teeth 

The  lower  teeth  are  more  difficult  to  extract  than  the 
upper  ones  because  of  the  inability  to  see  them  as  well. 

The  cheeks  and  the  lips  are  more  obstructive  and  the 
tongue  is  generally  in  the  way.     Care  must  always  be 


Fig.  58. — Position  of  operator.     Extracting  teeth,  lower  central  incisors. 
Protection  of  lips  with  fingers  of  left  hand. 

taken  not  to  tear  the  gums  or  catch  the  tongue  in  the 
forceps. 


The  Central  and  Lateral  Incisors  and  Canine 

These  teeth  have  all  straight  compressed  roots  except 
the  cuspid  which  is  sometimes  wavy  and  rounded.  Their 
extraction  will  be  considered  in  one  description. 


DENTAL  EXTRACTIONS 


121 


Position  as  shown  in  Fig.  58. 

Carry  the  lips  away  with  the  left  hand  and  apply  the 


i&ft 

^ 

* 

J 

IT 

©1 

Fig.  59. — Forceps   in   position.     Extraction  lower  incisor. 


Fig.  60. — Position  of  hand  and  thumb  gripping  forceps  for  lower  anterior 
teeth  and  lower  roots. 


forceps  as  shown  in  Fig.  59,  press  firmly  down  under  the 
gums  and  with  an  inward  and  outward  motion  rock  the 


122 


FIRST  AID  DENTISTRY 


tooth  and  when  loosened  withdraw.  Care  must  be  taken 
in  withdrawing  these  teeth,  not  to  let  the  forceps  strike 
the  upper  teeth  when  the  tooth  comes  out. 

The  canine  will  give  some  trouble,  as  this  root  is  much 
longer  than  the  others  and  being  rounded  a  rotary  motion 
will  be  added  to  the  above  process. 


Fig.  6i. — Position  of  operator.     Extraction  of  teeth — lower  left  side  of 

jaw. 

The  roots  of  these  teeth  will  seldom  be  presented  for 
extraction,  neither  will  the  teeth  except  when  loosened  by 
pyorrhea  alveolaris. 

The  Lower  First  and  Second  Bicuspids 

The  roots  of  the  first  and  second  bicuspids  are  generally 
the  same.  The  first,  however,  has  two  canals,  but  the 
roots  are  generally  not  separated. 


DENTAL  EXTRACTIONS 


123 


Fig.  62. — Position  of  operator.     Extraction  of  teeth — lower  right  side. 


Fig.  63. — Forceps  in  position.     Extraction  lower  cuspid. 


124  FIRST  AID   DENTISTRY 

They  are  compressed  and  round  and  slightly  flattened. 

The  position  will  be  taken  as  shown  in  Fig.  61  or  62. 

The  forceps  may  be  used  as  shown  in  Fig.  58  or  64,  and 
applied  as  shown  in  Fig.  64. 

Press  down  well  and  rock  the  tooth  with  a  direct  inward 
and  outward  motion,  until  the  tooth  is  loosened  and  then 


no.  64. — Extraction  of  lower  left  bicuspids. 

withdraw  it.  These  teeth  will  generally  give  little  trouble 
if  the  forceps  are  properly  applied. 

Press  the  alveolar  process  together  with  the  finger  and 
thumb. 

Their  roots  are  somewhat  difficult  to  extract  if  broken 
off  under  the  process. 

Lance  to  the  bone  on  either  side  and  with  the  root  for- 
ceps shown  in  Fig.  60,  squeeze  through  the  process  and 
the  tooth  can  be  withdrawn. 


dental  extractions 
The  Lower  First  Molar 


125 


Two  long  roots,  generally  curved  backward,  slightly. 
Consult  Fig.  14,  Chapter  V.  One  anterior  and  one  pos- 
terior root,  which  are  separated  about  the  center  of  the 
tooth.  Molar  forceps  are  made  with  points  and  grooves 
on  the  beaks  to  fit  in  this  space,  between  the  roots,  Fig. 
65.     Fig.  66  shows  a  "hornbeak"  forceps  in  proper  posi- 


Fig.  65.— Extraction    of    the    lower    left    first    molar. 

tion,   the  points  of  the  beaks  here  are  received  in  the 
separation  ot  the  roots,  Fig.  67. 

The  forceps  are  pressed  well  down  until  the  beaks  go 
home  around  the  roots.  The  tooth  is  rocked  in  and  out 
and  will  generally  give  way  and  then  may  be  removed. 
Sometimes,  however,  it  is  necessary  to  keep  up  this  motion 
while  withdrawing  from  the  socket. 


126 


FIRST  AID   DENTISTRY 


Fig.  66. — Extraction  of  lower  molars  with  a  hornbeak  forceps. 


Fig.  67. — Position  of  hand,  gripping  hornbeak  forceps  for  lower  molar, 
side  view  of  thumb  between  handles  to  prevent  crushing. 


DENTAL   EXTRACTIONS 


127 


Fig.  68. — The  elevator  in  position  for  the  extraction  of  roots. 


Fig.  69. — Extraction  of  lower  right  second  molar. 


128 


FIRST  AID  DENTISTRY 


The  roots  of  this  tooth  are  more  prone  to  break  than 
others  and  will  be  removed  with  the  lower  root  forceps, 
Fig.  58.  With  only  one  root  remaining  in  the  socket  the 
elevator  as  shown  in  Fig.  68  may  be  inserted  in  the  empty 
socket  and  the  root  pried  from  its  seat. 

The  Second  Molar 

Two  roots,  the  same  in  the  first  molar,  but  not  so  diverg- 
ing.    Consult  Fig.  14,  Chapter  V.     The  same  forceps  used 


Fig.  70. — The  extraction  of  the  lower  left  second  molar. 


and  the  same  procedure  in  the  extracting  as  the  first  molar ; 
using  an  in-and-out  motion,  and  again  being  careful  to  have 
the  beaks  well  down  in  the  bifurcation  of  the  roots.  Figs. 
69  and  70. 


DENTAL   EXTRACTIONS 


129 


The  Third  Molar 
(Wisdom  Tooth) 

This  tooth  is  the  most  difficult  of  all  to  extract  because 
of  its  varying  number  of  roots  and  its  frequent  malposition. 

Take  a  position  as  shown  in  Fig.  61  or  62,  right  or  left, 
select  a  forcep  with  a  short  thick  beak  or  the  lower  root 
forceps,  Fig.  58.     Forceps  shown  in  Fig.  69  can  also  be 


Fig.  71. — The  extraction  of  lower  third  molars,  wisdom  teeth. 

used  to  good  advantage,  except  that  there  is  a  possibility 
of  the  tooth  slipping  out  of  the  beaks  into  the  throat. 

Place  the  inner  beak  over  the  inside  of  the  tooth  and 
guided  by  the  fingers  of  the  left  hand,  the  outer  end  is 
brought  to  place,  Fig.  71. 

The  large  thickness  of  bone  on  the  outside  of  this  tooth 
renders  the  outward  motion  useless.  Turn  the  tooth  di- 
rectly inward,  keeping  a   good  pressure  on  the  forceps. 


13° 


FIRST  AID   DENTISTRY 


This  is  just  the  opposite  to  the  process  necessary  in  the 
upper  third  molar. 

These  teeth  are  malposed,  at  times  to  such  an  extent 
that  without  an  operation  which  first  aid  in  extracting 
would  justify,  their  extraction  is  impossible.  Impactions 
often  occur  such  as  is  shown  in  radiograph  Fig.  72,  and 
Fig.  73- 

In  Fig.  73  the  tooth  was  erupting  directly  toward  the 
outside.  An  inexperienced  operator  had  failed  in  extrac- 
tion of  the  second  molar. 


Fig.  72.  Fig.  73. 

Fig.  72. — Impacted    third   molar.     Radiograph. — (Author's  practice.) 
Fig.  73. — Impacted    third    molar,    with   fractured   remains   of   lower 
second  molar  from  faulty  extraction  by  inexperienced  operator.     Radio- 
graph.— (Author's  practice.) 

When  impacitons  occur  such  as  would  necessitate  an 
oral  operation,  the  first  aid  or  emergency  might  justify 
the  extraction  of  the  second  molar,  when  in  majority  of 
cases  the  trouble  will  be  ended. 

The  use  of  elevators,  as  shown  in  Fig.  68,  may  be  very 
advantageous  with  these  teeth. 


An  Improvised  Dental  Chair 

In  the  ordinary  medical  office,  hospital  or  in  the  field, 
the  question  of  a  proper  dental  chair  arises. 


DENTAL   EXTRACTIONS 


131 


Figs.  74,  75  and  76  show  the  patient  seated  in  a  com- 
mon chair  and  the  back  of  another  resting  against  this, 
the  left  foot  of  the  operator  on  the  second  chair,  a  head 
rest  is  made  by  the  knee.  Excellent  results  and  control 
of  the  patient  may  be  had  in  this  manner. 

The  patient  may  push  back  and  if  he  does  this,  the  head 


r  Fig.  74. — Position  of  patient  and  operator  in  improvised  Dental  Chair: 
Two  common  chairs  placed  back  to  back,  patient's  head  on  operator's 
knee.     Extraction  of  upper  teeth. 


will  force  the  operator's  knee  down  and  press  down  on  the 
chair  at  the  back. 

The  head  may  be  placed  on  any  point  of  the  operator's 
thigh  to  give  a  good  view  of  the  teeth  to  be  extracted  on 
either  side  of  the  mouth. 

For  the  lower,  Fig.  75,  the  head  will  be  rested  in  the 
thigh  and  against  the  body  of  the  operator. 


I32  FIRST  AID  DENTISTRY 


Fig.  75- — Improvised  chair  for  extraction  of  the  lower  teeth,  showing 
head  resting  on  thigh  and  against  body  of  operator. 


DENTAL   EXTRACTIONS 


*33 


Fig.  76. — Extraction  of  upper  teeth,  left  side.     Same  improvised  chair. 


CHAPTER   XIV 
POST-OPERATIVE  CONDITIONS 

Pain  after  Extractions 

Pain  after  extractions  may  be  a  result  of  injury  to  the 
peridental  membrane  or  to  the  alveolar  process;  spreading 
or  compressing  its  plates,  or  to  the  gum  tissue. 

The  mouth  being  full  of  foul,  septic  matter,  infection 
may  later  occur  with  resultant  pain.   ... 

The  mouth  as  stated  before,  should  be  syringed  out 
with  a  good  antiseptic  wash  and  the  instruments  be  abso- 
lutely sterile,  then  painting  the  parts  with  tincture  of 
iodine  will  be  considered  a  sufficient  precaution. 

Infection  of  sockets  in  many  cases  following  the  extrac- 
tion of  one  or  a  number  of  teeth  is  unnecessary.  If  the 
proper  precautions  are  taken  it  will  occur  only  in  a  very 
small  percentage  of  cases. 

A  record  of  five  months  of  the  writer's  practice  shows 
1,161  teeth  (including  many  badly  necrosed  roots)  ex- 
tracted with  a  result  of  four  cases  of  infected  sockets. 

After  the  removal  of  the  tooth  and  the  compression  of 
the  alveolar  process,  the  sockets  will  be  washed  out  with 
a  hot  solution.  No  cotton  or  medicine  of  any  kind  should 
be  placed  in  them. 

If  the  gums  are  lacerated  and  the  wound  is  gaping  open, 
the  cut  or  hanging  tissue  should  be  removed,  with  a  small 
pair  of  curved  scissors.  Any  points  or  jagged  portions  of 
the  alveolar  process  should  be  broken  down  and  smoothed 
over,  with  an  elevator  or  a  pair  of  forceps.  Then  paint 
this  part  with  tincture  of  iodine. 

134 


POST-OPERATIVE    CONDITIONS  135 

In  case  of  pain,  after  this  treatment,  make  a  paste  of 
iodoform,  orthoform  and  campho-phenique  and  saturate 
a  strip  of  gauze,  fold  this  into  the  socket,  leaving  it  for 
twenty-four  hours. 

A  case  dismissed  may  present  in  three  or  four  days, 
with  pain  and  infection  in  the  socket.  Wash  out  the 
mouth  with  a  hot  antiseptic  and  with  a  pair  of  tweezers 
and  sterile  cotton  remove  all  the  clot  in  the  socket  and 
flush  out  with  a  hot  solution. 

The  writer  paints  this  with  a  very  small  pledget  of 
cotton  saturated  in  tincture  of  iodine,  and  applies  the 
above  paste.  The  tincture  of  iodine  does  no  special  good 
in  this  case,  where  the  paste  is  to  be  applied,  except 
possibly  to  reduce  the  pain  while  inserting  the  gauze. 

In  nearly  all  cases  of  pain  and  infection,  this  paste  will 
prove  very  efficient,  the  iodoform  being  antiseptic  and  the 
orthoform,  a  magic  specific1  for  painful  wounds,  being  a 
local  anaesthetic,  while  the  campho-phenique  serves  as  a 
menstruum  in  mixing  and  appears  to  lessen  the  odor  of 
the  iodoform. 

Hemorrhages  after  Extractions 

Post-extraction  hemorrhages  may  be  very  severe,  even 
in  the  absence  of  hemophilia.  These  cases  are  not  rare 
but  are  liable  to  be  found  at  any  time  and  must  be  dealt 
with  wisely  and  promptly.  All  patients  should  be  ques- 
tioned as  to  liability  of  hemorrhage,  or  if  "bleeders"  (the 
common  name  for  hemophiliacs)  are  in  the  family. 

The  death  of  a  United  States  Senator,  in  recent  years, 

was  caused  by  hemorrhage  from  the  extraction  of  a  tooth 

and  all  known  methods  of  treatment  in  this  case  were 

exhausted. 

1  Buckley. 
10 


136  FIRST  AID  DENTISTRY 

Hemorrhage  from  a  socket  may  be  capillary  or  arterial, 
and  unless  trie  patient  is  of  a  hemorrhagic  diathesis,  little 
difficulty  will  be  experienced  in  stopping  the  bleeding. 

Slight  bleeding  will  yield  sometimes  to  the  holding  of 
ice  water  over  the  socket.  If  no  ice  can  be  had  a  very 
hot  solution  will  serve,  used  as  hot  as  the  patient  can 
stand  it. 

The  use  of  persulphate  of  iron  should  not  be  restored 
to  until  all  other  remedies  fail. 

If  the  cold  or  hot  water  does  not  stop  the  flow,  the  paste 
of  iodoform,  orthoform  and  campho-phenique  on  a  folded 
piece  of  gauze,  packed  tightly  in  the  socket  will  answer 
in  most  cases.  A  gauze  pack  of  tannic  acid  in  glycerine 
will  serve  also,  forced  to  the  bottom  of  the  socket.  These 
packs  will  be  observed  daily  and  left  until  there  is  no 
danger  of  recurrence. 

In  hemophilia,  the  use  of  tampons  and  mechanical  appli- 
ances will  be  necessary.  The  writer  recommends  the  in- 
sertion of  a  gauze  strip,  longer  than  will  be  necessary, 
saturated  with  the  paste  of  glycerite  of  tannin,  folded 
upon  itself  to  the  bottom  of  the  socket,  when  the  gauze 
is  flush  with  the  gums,  cut  off  the  excess,  fit  a  piece  of 
cork  over  the  socket,  letting  it  extend  down  into  the  open- 
ing and  trim  it  to  the  height  of  the  teeth.  Pressure  is 
then  made  on  this  by  a  figure-of-eight  ligature  around  the 
two  teeth  adjoining  the  socket,  which  serves  to  hold  it 
in  position.  This  cork  may  be  held  in  place  also,  by  the 
use  of  the  Barton  bandage,  the  former  is  preferable,  when 
the  teeth  are  present  for  attachment  of  the  ligatures. 

In  extreme  cases,  the  tooth  antiseptically  treated  may 
be  replaced  in  the  socket. 

The  internal  treatment  should  be  conducted  by  the 
surgeon  who  will  administer  drugs  which  increase  the 
coagulability  of  the  blood.     Those  most  commonly  used 


POST-OPERATIVE   CONDITIONS  137 

are  calcium  chloride  and  calcium  lactate,  3-10  grains  or 
0.2-  to  0.6-crm.  doses. 


Fainting 

Patients  may  faint  in  the  operations  on  the  teeth  or 
even  before,  from  the  sight  of  the  instruments  or  from 
fear. 

The  condition  is  the  result  of  the  passing  of  the  blood 
from  the  head,  especially  the  brain,  which  becomes  anemic. 
It  is  generally  merely  a  physical  problem  to  lower  the 
head  and  let  the  blood  run  back.  A  patient  who  turns 
pale  and  blanches  may  have  his  head  lowered  between  his 
knees  for  a  few  moments,  which  will  revive  him. 

Dashing  cold  water  in  the  face  or  the  odor  of  ammonia 
will  aid.  In  case  these  methods  fail,  from  10  to  20  drops 
of  aromatic  spirits  of  ammonia  in  water  may  be  given, 
this  being  a  cardiac  and  respiratory  stimulant. 

In  extreme  cases  a  pearl  of  amyl  nitrite  may  be  broken 
in  a  handkerchief  and  held  close  to  the  patient's  nose. 


CHAPTER  XV 

DISEASES  OF  THE  MAXILLARY  SINUS-ANTRUM 
OF  HIGHMORE 

This  chapter  is  intended  for  Surgeons  and  Dental  Sur- 
geons only. 

The  operations  and  care  of  the  above  conditions  must 
be  considered  under  emergency  treatment,  although  not 
strictly  first  aid. 

The  surgeon  or  dental  surgeon  where  the  diagnosis  of 
the  condition  is  determined,  cannot  fail  to  see  the  necessity 
for  emergency  treatment.  The  methods  of  operation  and 
treatment  here  described  have  given  the  writer  and  others 
such  results  that  they  are  highly  recommended. 

Diseases  of  the  maxillary  sinus  are  much  more  common 
than  is  supposed  "they  are  common  among  the  lower  class 
of  society,  or  people  who  neglect  their  teeth."1  There 
are  various  diseased  conditions  found  affecting  the  sinus, 
among  which  are  suppurative  inflammation  of  purulent 
empyema,  mucous  engorgement,  syphilitic  ulceration,  ne- 
crosis of  the  bony  walls,  tumors  and  dentigerous  cysts, 
containing  unerupted  teeth,  deciduous  permanent  or 
supernumerary. 

This  chapter  will  consider  only  the  suppurative  inflam- 
mation or  purulent  empyema,  which  has  for  its  etiology, 
local  conditions  and  diseases  of  the  teeth,  injurious  catar- 
rhal affections,  foreign  bodies,  present  in  the  cavity  and 
dentigerous  cysts. 

All  of  the  diseases  of  the  teeth  that  have  been  taken 
up  in  this  book  which  are  located  in  the  root  canals,  are 
etiological  factors,  especially  those  with  putrescent  pulps 

1  Marshall. 

138 


DISEASES   OF   THE   MAXILLARY   SINUS  139 

and  acute  and  chronic  abscesses.  The  roots  of  the  su- 
perior teeth,  as  previously  shown,  the  cuspids,  bicuspids 
and  molars,  are  separated  from  the  cavity  by  a  thin  floor 
of  bone.  In  the  formation  of  abscesses,  this  tissue  is 
easily  destroyed  and  the  drain  of  the  pus  is  directly  into 
the  sinus. 

Injuries,  which  fracture  the  bones  of  the  face  are  prone 
to  result  in  infection  of  the  sinus,  especially  if  the  wound 
communicates  with  the  mouth  and  gives  access  to  the  oral 
fluids.  Other  injuries  spoken  of  as  causes  of  empyema 
are  the  fracture  of  the  process  and  the  removal  of  portions 
of  the  floor  in  extraction  of  the  teeth. 

Among  common  causes  are  the  catarrhal  affections  of 
the  nasal  tract  resulting  in  the  inflammation  of  its  mem- 
brane which  is  continuous  with  the  membrane  lining  the 
maxillary  sinus. 

Another  cause  is  the  presence  of  foreign  bodies  in  the 
sinus,  and  in  this  class  of  causes  dentigerous  cysts  are 
first  to  be  considered.  Nature  tries  to  expel  the  teeth 
forcibly  and  they  become  sources  of  irritation  and  result 
in  severe  cases  of  pus  formation.  Other  foreign  bodies 
such  as  dental  material,  root-fillings,  etc.,  may  be  forced 
through  the  root  into  this  cavity.  Insects  may  be  taken 
in  through  the  nose  and  find  their  way  into  this  sinus. 

The  symptoms  of  suppuration  of  the  sinus  are  pain, 
dull  and  deep-seated,  which  later  becomes  intense  and 
extends  over  the  whole  side  of  the  head  and  face.  The 
walls  of  the  Antrum  of  Highmore  become  thin  and  Mar- 
shall states  that  under  pressure  they  give  forth  a  crack- 
ling sound  like  that  of  the  crushing  of  an  egg  shell. 

The  orbit  forming  the  roof  of  the  sinus,  suppuration 
evprts  its  pressure  on  this  and  at  times  forces  the  eyeball 
to  a  marked  protrusion  and  causes  paralysis  of  the  optic 
nerve  from  this  force. 


I/J.O  FIRST  AID   DENTISTRY 

If  the  discharge  of  pus  is  directed  into  the  nose,  the  odor 
of  the  breath  is  very  offensive.  The  condition  is  clearly 
one  demanding  prompt  and  decisive  action. 

The  diagnosis  is  at  times  somewhat  difficult.  The  use 
of  a  light  shadowing  through  the  sinus,  the  soreness,  pain 
and  swelling  on  the  side  of  the  face  affected.  In  unilateral 
or  both,  if  bi-lateral,  the  presence  of  pus  escaping  through 
the  nose,  when  the  head  is  held  down  and  quickly  thrown 
back  and  to  the  opposite  side,  the  soreness  of  the  teeth, 
the  crepitus  of  the  thinner  part  and  the  X-ray  for  foreign 
bodies  are  the  means  of  diagnosis.  The  radiograph  is  the 
most  satisfactory  method  of  locating  foreign  bodies  and 
determining  the  condition. 

Treatment 

In  every  disease,  the  removal  of  the  cause  is  the  first 
thing  to  be  considered,  so  with  the  maxillary  sinus  affec- 
tions, but  when  the  cavity  is  full  of  pus,  it  demands  pri- 
marily, opening  and  drainage. 

A  local  anaesthetic  or  Nitrous  Oxide  and  Oxygen  or 
other  general  anaesthetic  may  be  used.  A  2  per  cent, 
solution  of  eucaine  or  cocaine  as  a  local  anaesthetic  is 
used  with  success,  but  novocaine  is  preferable  to  either 
of  these  and  all  other  local  anaesthetics. 

There  are  many  methods  of  operating  for  this  condition. 
Some  operators  extract  the  first  molar  or  bicuspid  tooth 
and  make  an  entrance  into  the  sinus,  through  the  sockets 
of  these  with  a  trephine  or  engine  drill.  Marshall  has 
devised  an  excellent  trocar  and  canula  for  this  operation 
and  in  this  method  of  entrance  it  is  very  desirable. 

The  writer  recommends  the  method  shown  in  Fig.  77. 
A  root  reamer  burr  is  selected  for  the  dental  engine.  The 
distance  determined  that  the  drill  should  enter  and  a  gutta- 


DISEASES    OF    THE    MAXILLARY    SINUS 


141 


percha  ball  placed  on  the  burr  at  this  point,  to  prevent 
its  slipping  and  puncturing  the  floor  of  the  orbit.  Make 
an  incision  well  up  over  the  side  of  the  roots  of  the  second 
bicuspid  and  first  molar  teeth;  insert  the  drill  between 
the  roots.  An  opening  as  large  as  an  ordinary  lead  pen- 
cil will  suffice  for  suppuration,  unless  the  removal  of 
foreign  matter  requires  a  larger  one.     This  is  the  best 


Fig.  77. — Empyema  of  the  Antrum  of  Highmore,  position  showing 
method  of  opening  with  drill,  with  gutta-percha  guard,  between  the 
roots  of  the  second  bicuspid  and  the  buccal  root  of  the  first  molar. 


place  in  the  mouth  to  open  into  the  antrum  because  it 
is  a  dependent  portion  and  is  better  than  going  through 
a  tooth  socket  because  the  food  and  oral  secretions  do 
not  have  access;  since  the  cheek  covers  the  wound. 
Where  the  dental  engine  is  not  available  or  desired,  the 
chisel  and  hammer  may  be  nicely  used,  the  opening  being 
made  large  enough  to  admit  exploration  with  the  fingers 
if  desired  to  remove  foreign  bodies. 


142  FIRST  AID  DENTISTRY 

E.  J.  Craig  of  Kansas  City  has  a  method  of  making  a 
drain  as  follows:  Take  a  silver  wire,  20  gauge,  wind  it 
over  a  handle  slightly  smaller  than  the  opening,  to  make  a 
close  coil  about  1  inch  in  length;  this  may  be  bent  in 
any  direction.  Insert  it  in  the  opening  and  keep  it  there 
for  one  or  two  days.  Flatten  the  outer  end  so  that  it  will 
not  irritate  the  buccal  tissue.  This  drain  will  not  work 
through  into  the  antrum  as  many  drains  are  liable  to  do 
and  it  affords  entrance  for  the  syringe  tip.  The  opening 
will  not  close  after  its  removal  if  left  for  two  or  three  days. 

The  cavity  should  be  syringed  out  with  a  normal  salt 
solution,  ioo°  temperature  from  a  Moffat  syringe,  or  a 
fountain  syringe,  with  a  glass  nozzle  made  to  fit  the  case, 
the  bag  containing  the  water  held  not  higher  than  the 
patient's  head,  in  the  first  few  sittings. 

The  use  of  10  per  cent,  argyrol  solution  is  an  excellent 
remedy  after  the  drain  has  been  perfected  through  the 
nose.  Harlan  recommends  in  chronic  cases,  after  irrigat- 
ing as  long  as  deemed  necessary,  flooding  the  cavity  with 
a  2  per  cent,  silver  nitrate  solution,  which  makes  a  pro- 
found impression  on  the  tissues  and  further  treatment  is 
unnecessary. 

In  chronic  cases  which  have  large  openings,  from  an 
operation  to  remove  foreign  matter,  the  bismuth  paste 
given  in  a  previous  chapter  is  injected  by  some  operators 
with  great  success.  The  cavity  after  operation  is  packed 
with  this  paste  on  gauze,  continuing  the  washing  with 
the  warm  saline  solution  for  time  desired.  An  operation 
for  a  typical  case  of  dentigerous  cyst  was  performed  at 
a  convention  of  the  New  York  State  Dental  Society,  by 
Dr.  Henry  Sage  Dunning,  of  New  York,  Dr.  Dunning  has 
very  kindly  furnished  the  following  description  of  same 
with  use  of  plates. 

"Patient,  young  Swede,  seventeen  years  old,  came  to 


DISEASES   OF   THE   MAXILLARY   SINUS 


143 


clinic  complaining  of  swollen  face,  upper  right  side  and 
slight  pain.  Patient  said  that  the  face  had  been  swollen 
for  about  eight  to  ten  months.  Sometimes  swelling  would 
increase  and  become  hard  and  then  would  get  smaller  or 
go  down  and  patient  thinks  he  would  at  this  time  notice  a 
discharge  in  the  mouth. 

Examination. — Face,  swelling  of  face  marked,  extending 
from  infraorbital  region  to  alveolar  process  and  from  ala 
of  nose  to  zygomatic  arch,  the  entire  wall  of  antrum  was 
ballooned  anteriorly  about  1/  2  to  3/4  of  an  inch.     Bony  wall 


Supernu- 
merary 
tooth 


Unerupted 
canine 


Necrosed 

end  of 

bicuspids 


Fig.  78. — Dentigerous  cyst  in  the   maxillary  sinus.     Radiograph. 
— (Dr.  Dunning' s  practice.)     Case  cited. 

of  antrum  greatly  thinned  out  and  a  distinct  egg-shell 
crackle  noted.  Somewhat  tender,  above  area  somewhat 
red  and  slightly  warmer  than  on  other  side.     Fig.  78. 

Mouth,  central  lateral,  first  bicuspid,  second  bicuspid, 
first  and  second  molar  in  position,  and  in  good  condition. 
Third  molar  'erupting,  canine  missing,  and  space  of  1/2 
inch  between  lateral  and  first  bicuspid.  Marked  swelling 
over  alveolar  ridge,  extending  from  canine  fossae  to  second 
molar  region.  This  swelling  was  oval  in  shape  and  was 
about  the  size  of  a  pigeon  egg.     External  plate  was  thin 


144  FIRST  AID   DENTISTRY 

and  egg-shell  crackle  noted  as  on  face.  Small  sinus  noticed 
just  over  the  lateral  and  probe  could  be  passed  along  neck 
of  this  tooth  into  its  alveolus,  up  into  large  cavity  for  a 
distance  of  about  i  inch.  X-ray  showed  non-erupted 
permanent  canine  just  over  lateral  root,  and  above  this 
there  was  shown  another  tooth,  which  looked  like  a  super- 
numerary tooth.  Large  cavity  shown  by  X-ray  to  involve 
antrum,  but  unable  to  tell  by  film  to  what  extent.  Roots 
of  the  two  bicuspids  somewhat  absorbed  and  extending 
into  the  cyst  cavity. 

Diagnosis. — A  true  dentigerous  cyst,  containing  two 
teeth.     Nose  examined,  negative;  ear  examined,  negative. 

Operation  performed  before  the  members  of  the  New 
York  State  Dental  Convention  at  Albany,  New  York. 
Patient  given  1/6  grain  morphine  by  hypodermic  to  quiet 
him  and  to  relieve  from  post-operative  pain.  Cyst  area 
painted  with  1/2  strength  iodine.  One  per  icent.  novo- 
caine  injected  into  swelling  of  alveolar  border,  deeply 
into  periosteum  and  bone.  An  incision  was  then  made 
along  swelling,  extending  from  lateral  to  second  molar. 
Soft  tissues  laid  back  and  bone  exposed.  Anterior  wall 
of  antrum  found  to  be  very  thin;  with  chisel  and  mallet 
broke  through  thin  external  alveolar  plate  and  found  large 
cavity  full  of  thick  yellow  pus,  containing  white  flakes. 
Enlarged  cavity  quickly  and  entire  wall  of  antrum  found 
to  be  thin,  soft  and  necrotic  in  places.  With  rongeur 
forceps  removed  large  area  of  diseased  anterior  wall  and 
made  opening  into  the  antrum,  that  would  allow  passage 
of  ends  of  four  fingers  of  hand.  Excavated  about  1  1/4 
ounces  of  thick  pus,  irrigated  the  cavity  with  warm  saline 
solution  and  for  the  first  time  obtained  good  view  of  the 
cavity.  Cavity  extended  from  floor  to  alveolar  ridge  of 
orbit,  from  second  molar  to  lateral  and  upward  to  floor 
of  nose.     Cavity  lined  with  smooth  thin  membrane  or 


DISEASES    OF   THE    MAXILLARY   SINUS 


145 


sac,  which  was  partly  removed  by  the  operator.  Cavity 
curetted  and  two  teeth,  a  temporary  canine  and  perma- 
nent canine  dislodged  from  bony  wall.  Rough  edges  of 
thin  bone  surrounding  opening  into  cavity  smoothed  off 
and  cavity  packed  with  bismuth  paste  and  gauze.  This 
cyst  cavity  was  found  to  connect  directly  with  the  nose. 
The  membrane  lining  the  bone  cavity  seemed  to  wall  off 
nose  at  middle  meatus,  the  natural  communication  of  the 

Cyst  cavity 
filled  with 
Bismuth 


Fig.  79. — After  operation-cavity  rilled  with  bismuth  paste. 


nose  and  antrum.     A  puncture  through  the  nose  into  the 
cavity  was  performed  to  establish  better  drainage. 

Treatment — Cavity  has  been  packed  with  bismuth  paste 
gauze  and  irrigated  with  warm  saline  solution  about  three 
times  a  week  for  the  last  three  months.  Opening  has 
closed  in  considerable  but  cyst  cavity  about  the  same  size. 
Tissues  are  clean  and  healthy. 


146  FIRST  AID   DENTISTRY 

Prognosis. — Opening  into  cyst  cavity  and  antrum  will 
continue  to  fill  in,  but  will  never  completely  close.  No 
danger  of  recurrence,  as  lining  of  membrane  of  cyst  has 
been  removed  and  source  of  irritation,  the  teeth,  has  been 
removed.     Fig.  79. 


AUTHORS  AND  BOOKS  CONSULTED 

Abbott:  "Principles  of  Bacteriology." 

Allen:  "Vaccine  Therapy  and  Opsonic  Treatment." 

"American  Text-book  of  Operative  Dentistry." 

Black:  "Dental  Anatomy." 

Bodecker:  "Anatomy  and  Pathology  of  the  Teeth." 

Broomell:  "Anatomy  and  Histology  of  the  Mouth  and  Teeth." 

Buckley:  "Modern  Dental  Materia  Medica,  Pharmacology  and 

Therapeutics." 
Buechard:  "Dental  Pathology,  Therapeutics  and  Pharmacology." 
Burchard  and  Inglis :  "Dental  Pathology  and  Therapeutics." 
Burr,  Aaron:  "Dental  Cosmos." 
Cryer:  "Internal  Anatomy  of  the  Face." 
Da  Costa:  "Gray's  Anatomy." 
"Dental  Cosmos." 
Gorgas:  "Dental  Medicine." 
Harlan:  "Lectures." 
Hunter:  "Oral  Sepsis." 
"Items  of  Interest." 
Jackson:  "Orthodontia." 

Johnson:  " Principles  and  Practice  of  Filling  Teeth." 
Keyes:  "Syphilis." 
Longmore:  "  Gunshot  Wounds." 
Marshall:  "Injuries  and  Surgical  Diseases  of  the  Face,  Mouth 

and  Jaws." 
Miller:  "Micro-organisms  of  the  Human  Mouth." 
Ottolengui:  "Methods  of  Filling  Teeth." 
Prinz:  "Dental  Materia  Medica  and  Therapeutics." 
Stimson:  "Fractures  and  Dislocations." 
Talbot:  "Interstitial  Gingivitis." 
Tomes:  "Dental  Surgery." 
Wallis:  "Atlas  of  Dental  Extractions." 
Zeigler:  "Pathology." 


147 


INDEX 


Abrasion,  mechanical,  43 
Abscess,  acute  alveolar,  46,  49 
treatment,  65-67 
abortive,  65,  66 
drainage,  66,  67 
general,  66 
lancing,  66 
local,  65 
chronic  alveolar,  49 

antrum  of  Highmore,  50 
cause  and  classification,  49 
diagnosis,  51 
situation,  50 
chronic,  without  fistula,  cause,  49 
perforated  roots,  68 
treatment,  67 
chronic,  with  fistula,  extraction, 
69-70 
irrigation,  70 
treatment,  69 
Absence  of  proper  teeth  for  masti- 
cation, 4 
Absorption,  vaccine  and  bacteria,  3 
Alimentary  tract,  2 
Alveolar  process,  40,  41 
Alveoli,  necrosed,  5 
Anatomy,  dental,  34 
Anemia,  mouth  organisms,  3 
Antiseptic  mouth  wash,  value  of,  5 
Antrum  of  Highmore,  diseases  of, 
cause  and  symptoms  of, 

139 
diagnosis,  140 
drainage,  142 
history   of    case    of    dentigerous 

cyst,  142 
diagnosis,  144 


Antrum,    history    in   examination, 

143 
operation,  144 
prognosis,  146 
treatment,  145 
method  of  entrance,  141 

purulent  empyema  of,  138 
treatment,  140 
Articular  rheumatism,  3 


B 


Bacillus  pyocyaneus,  1 

Bacteria,  presence  of  in  the  mouth, 

absorption  of,  2 
Brushing  of  teeth  properly,  12 


Calco  spherites,  43 
Calculus,  serumal,  7-15 

salivary,  8-15 

technique  of  removal,  9-15 
Campho-phenique,  54 

-iodoform-orthorform    paste    for 
painful  sockets,  5 
Canker  "sore  mouth,"  cause,  18 

description,  18 

treatment,  191 
Carbolic  acid,  54 
Cause  of  gastric  disorders,  4 
Cementosis,  74 
Cementum,  38 
Chancre  vs  herpes,  30,  31 
Chisel,  use  of,  58 

Chloroform,  aconite  and  iodine,  64 
Chronic  alveolar  abscess  (see  ab- 
scesses), 49 


149 


IS© 


INDEX 


Cicatricial  tissue  of  abscesses,  50 
Cloves,  oil  of,  54 
Cold  sores  (herpes  labialis),  17 
Conditions  of  the  mouth,  crowns, 
ill  fitting  dentures,  1 

necrosed  roots,  1 

pathogenic  bacteria,  1 

tartar,  1 
Cotton  pledgets,  use  of,  50-56 

rolls,  use  of,  54,  55,  57,  86,  87 
Counter  irritant,  64 
Cresol  and  formaldehyde,  63 


D 


Defective  fillings,  42 
Dental  anatomy,  34 
deciduous  teeth,  34 
eruption  of,  35 
extraction,  36 
pain,  42 
pulp,  39 

exposure  of,  42 
Dentine,  37,  38 
exposed,  73 

secondary,  cause  of  neuralgia,  73 
Deposits,  classification  of,  6,  7 
deposition  of,  7,  9 
location,  7 

technique  of  removal,  9-15 
Differential   diagnosis   of   chancre 

and  herpes,  30,  31 
Dislocation  of  lower  jaw,  anatomy, 
102 
percentage,  101 
symptoms,  103 
treatment,  103 
Dobell's  solution,  4,  53 
Dressing  pliers,  use  of,  52 


Enamel,  definition  of,  37 
Eruption  of  teeth,  36 
Eruptions,  syphilitic,  27,  30,  31 


Excavators,  use  of  52,  55,  56 
Explorer,  use  of,  52-55 
Exposed  dentine,  73 
Exposure  of  the  pulp,  42 
diagnosis,  43,  44 
treatment,  52 
Extractions,  accidents,  104 
choice  of  forceps,  108,  109 
handles,  109 
material,  109 
shape  and  size,  109 
sterilization,  109 
deciduous  teeth,  36,  105 
extraction   of   the   lower   teeth, 
central  and  lateral  incisor 
and  canine,  120-122 
first  and  second  bicuspids, 

122,  123,  124 
first  molar,  125-128 
second  molar,  128 
third  molar,  129,  130 
of    the    upper    teeth,    central 
incisor,  no,  in 
cuspid  or  canine,  114,  115 
lateral  incisor,  112 
first  and  second  bicuspids, 
116, 117 
molar  roots,  118 
molars,  117 
the  third  molar,  118,  119 
failures,  105 
improvised    dental    chair,    130- 

133 
infection,  106 
lancing,  107 
position  of  patient,  106 
post-operative  conditions,  134 

fainting,  137 

hemorrhage   after    extraction, 

135 
treatment,  136,  137 
pain  after  extraction,  134,  135 
preparation,  108 
procedure  of  extracting,  position 
of  patient,  109,  no 


INDEX 


151 


Facial  neuralgia,  73 

Fainting,  137 

Fever  blisters  (herpes  labialis),  17 

Fillings,  defective,  42 

removal  of,  59 
Formaldehyde,  63 
Fracture  of  teeth,  43 
Fractures,  cause,  88 
classification,  88 
treatment,  89 
inferior  maxilla,  88-90 
cases  cited,  90,  91 
classification,  90 
gunshot,  90 

incomplete      and      com- 
pound, 90 
bandaging,  98 
delayed  union,  treatment  of, 

100 
edentulous  jaws,  92 
frequency  of,  91 
traction  of  fragments,  99 
treatment,  92 
wax  molds,  93 
wiring  method,  95-98 


Herpes,  definition,  17 

differential  diagnosis  with  chan- 
cre, 30 
treatment,  18 
Hyperemia,     relative     to     dento- 
alveolar  abscess,  47 


111  fitting  dentures,  1 

favorable  for  growth  of  germs,  1 
stomatitis  from,  16 
Impacted  teeth,  74 
Incisor    tooth,    implantation    and 

structure,  37 
Infection  from  syphilis,  27-29 
immediate  prevention  from  acci- 
dental infection,  30 
Inflammation  of  the  dental  pulp,  42 
Injuries  of  the  mucous  membrane, 
cause,  19,  20 
treatment,  20 
Instruments,  108 

Iodine,    tincture    of,    for    infected 
sockets,  4 


Gingivitis,  definition,  21 
marginal,  cause,  21 
location,  21 
treatment,  23,  24 
Growth  of  disease  producing  germs 

in  mouth,  1 
Gum  boil,  50 
Gums,  50 
inflammation  of,  treatment,  5 


H 


Hemorrhage  after  extracting,  135 
Herpes  labialis  (fever  blisters),  17 
confusion  with  syphilitic  erup- 
tion, 27 


Jaws,  anatomy  of,  88 
fracture  of,  88-100 


Lancing,  66 

abscesses,  66 

in  extraction  of  roots,  107 
Local  cause  of  pyorrhea  alveolaris, 
79 

M 

Marginal  gingivitis,  21 
mouth  wash  for,  24 
Maxillary   sinus    (see    Antrum   of 

Highmore),  13S 
Mechanical  abrasion,  43,  59,  60 


152 


INDEX 


Mirror,  mouth,  use  of,  52,  54,  55 
Mouth  organisms,  diseases  attrib- 
uted to,  3 
Mucous    membrane,    injuries    of, 
cause,  19,  20 


N 


Necrosed  roots,   source   of   infec- 
tion, 4 
Neuralgia  (nerve  pain),  cause,  72, 

73 
description,  72 
facial  neuralgia,  cementosis,  74 

exposed  dentine,  73 

impacted  teeth,  74 

pericementitis,  74 

pulpitis,  73 

pulp  nodules,  73 

treatment,  75-77 


O 


Oil  of  cloves,  5 

Oral  cavity,  treatment  and  steril- 
ization, 4 


Pain;  dental,  42 

post-operative,  134 
Pathogenic  germs,  2 
Pericementitis,  74 
acute  septic  (dento-alveolar  ab- 
scess), cause,  46,  47 
diagnosis,  48 
pressure  of  blood,  48 
process  of,  47 
cause,  46 
definition,  46 

non-septic,  counter-irritation,  64 
diagnosis,  46 
treatment,  64 
Pericementum,  38,  39 
Post-operative  conditions,  134 


Primary  syphilis  (see  syphilis),  26 
Probe,  use  of,  51 

Ptyalism    (salivation),    cause    and 
appearance,  32 
treatment,  32,  33 
Pulp,  exposure  of,  42-44 
nodules,  73 
stones,  43 
Pulpitis,  42 
treatment,  5 

congested  pulp,  57 
mechanical  abrasion,  60 
neuralgia,  73 
proper  drugs  to  use,  54 
removal  of  filling,  59 
sterilization,  52,  53 
Pus,  abscesses,  46-50 
Putrescent  pulp,  cause,  45 
diagnosis,  45 
treatment,  61-63 

cresol  and  formaldehyde,  63 
sealing  of  treatment,  63 
three  important  factors,  61 
use  of  broaches,  62 
of  cotton  rolls,  61 
Pyorrhea  alveolaris,  absorption  of 
bacteria,  2 
acute  septic  pericementitis,  47 
classification  of  features,  78 
dento-alveolar  abscess,  47 
difference  in  etiology,  79 
local  •  and     general     etiology 
described,  79 
process  of  disease,  80 
diagnosis,  83 
extraction  of  teeth,  84 
general      and      constitutional 

causes,  81 
heredity,  86 

instrumentation     and     treat- 
ment, 84-87 


R 


Removal  of  deposits,  9-15 


INDEX 


153 


Salivary  deposits,  6,  8,  9 
Salivation  (ptyalism),  32 
Sandarac  varnish,  56 
Secondary  dentine,  43 
Serumal  deposits,  6,  7,  8 
Silver  nitrate,  60 
Smokers'  sore  mouth,  20 
Sockets,  pus  ridden,  4 

painful,  5 
Sore  mouth  (canker),  18 
Staphylococcus  pyogenes  albus,   1 
aures,  1 
citrus,  1 
Sterilization  of  instruments,  52 
Stomatitis,  causes,  16 
definition  and  classification,  16 
treatment,  17 
Streptococcus  pyogenes,  1 
Syphilis   in   the   mouth,    first    aid 
treatment,  25-30 
immediate    prevention    of    acci- 
dental infection,  30 
primary  syphilis,  infection  from, 
26 
secondary,  diagnosis,  27,  28 
nature  of  manifestations,  27 
sterilization  of  instruments,  25 
tertiary,  infection,  29 
nature  of  manifestations,  29 


Tartar,  6 

Teeth,  correct  method  of  brushing, 
12-14 

deciduous,  34-36 

fractures  of,  43 

impacted,  50 
Tincture    of    iodine,    aconite    and 

chloroform,  64 
Tonsilitis,  mouth  infection,  2 
Toothache,  42 
Tract,  abscess,  50,  47,  48 


Varnish,  sandarac,  dressing,  50 
Vaseline,  use  of  as  dressing,  56 

W 

Wash,  mouth,  3-5,  19,  24,  33 
X 

X-ray  in  fracture  of  maxilla,   95 
in  neuralgia,  74,  75 
in    treatment    of    chronic     ab- 
scesses, 5 


RK53 

R 

95 

Ryan 

First  aid  dentistry. 

1  0  1  %l 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RK  53  R95  C.1 

First  aid  dentistry. 


2002339315 


